Clinical Procedures for Safer Patient Care

Clinical Procedures for Safer Patient Care

Thompson Rivers University Edition

Renée Anderson, Glynda Rees Doyle, and Jodie Anita McCutcheon

Thompson Rivers University

Kamloops

Contents

1

About the Book

Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition was adapted by Renée Anderson, Thompson Rivers University from Glynda Rees Doyle & Anita McCutcheon, British Columbia Institute of Technology’s textbook Clinical Procedures for Safer Patient Care. The original textbook content was produced by Glynda Rees Doyle & Anita McCutcheon and is licensed under a Creative Commons Attribution 4.0 International license. The changes and additions noted below are © by Renée Anderson and are licensed under a  Creative Commons Attribution 4.0 International license

BCcampus Open Education began in 2012 as the B.C. Open Textbook Project with the goal of making post-secondary education in British Columbia more accessible by reducing students’ costs through the use of open textbooks and other OER. BCcampus supports the post-secondary institutions of British Columbia as they adapt and evolve their teaching and learning practices to enable powerful learning opportunities for the students of B.C. BCcampus Open Education is funded by the British Columbia Ministry of Advanced Education, Skills & Training, and the Hewlett Foundation.

Open educational resources (OER) are teaching, learning, and research resources that, through permissions granted by the copyright holder, allow others to use, distribute, keep, or make changes to them. Our open textbooks are openly licensed using a Creative Commons licence, and are offered in various e-book formats free of charge, or as printed books that are available at cost.

For more information about open education in British Columbia, please visit the BCcampus Open Education website. If you are an instructor who is using this book for a course, please fill out our Adoption of an Open Textbook form and let Renée  know.

The 2018 adaptation (TRU edition) includes the following changes: all learning objectives have been modified and are titled learning outcomes. All broken video links have been deleted. ‘Physician orders’ has been changed to ‘prescriber’s orders’. ‘Hospital’ has been changed to ‘agency’. All new figures that have been added have been attributed. Figures without attribution are present from the first edition. All critical thinking exercises have been modified. Where possible reference lists have been added to, some links have been updated. ‘Perform point of care risk assessment for PPE’ has been added to each appropriate checklist. In addition:

Chapter 1: Infection Control

Chapter 2: Patient Assessment

Chapter 3 now called Safer Patient Handling, Positioning, Transfers and Ambulation

Chapter 4: Wound Care

Chapter 5: Oxygen Therapy

Chapter 6: Non Parenteral Medication Administration

Chapter 7: Parenteral Medication Administration

Chapter 8: Intravenous Therapy

Chapter 9: Blood Glucose Monitoring

Chapter 10: Tubes and Devices

2

Acknowledgments

Special thanks to those without whom this adapted book would not have been possible.

Thank you to Glynda Rees Doyle, Jodie Anita McCutcheon and the team that put together the original text book. Your work is high quality and has made the adaptation for use at Thompson Rivers University School of Nursing so much easier.

Thank you to Leon Racicot (TRU Media Services) for filming the videos and editing.  Thank you to my nursing colleagues Wendy McKenzie, Kim Morris, Shari Caputo, Candace Walker, Joanne Jones and Kathryn Smith all Registered Nurses and all nurse educators who graciously shared their talents and expertise. In some cases it was in the creation of videos, sometimes it was in reviewing content and providing expert feedback;  other times the collection of student feedback as the text was trialed with students.

Thank you to the TRU  community who supported this work through a OER development grant including the Centre for Excellence in Learning and Teaching, to the Open Learning colleagues who are experts in their craft and to administration who support the idea of open educational resources for students. Thank you Open Learning Faculty – Nicole Singular, Patrice Hall, Christopher Ward and Jon Fulton for your support with formatting, copyrighting, editing, and tech support respectively.

Finally, thank you to my family for their support, encouragement, and patience in the journey through writing this resource, and the unanticipated additional hours and hours of work.

3

Introduction

In Canada, there continues to be overwhelming evidence that significant preventable harm and patient care errors continue to occur despite the fact that most health care providers are committed to providing safe patient care and to do no harm (Baker et al., 2004; Butt, 2010). Health care-associated errors or near misses are rarely the result of poor motivation, negligence, or incompetence, but are based on key contributing factors such as poor communications, less than optimal teamwork, memory overload, reliance on memory for complex procedures, and the lack of standardization in policies and procedures in health care (Canadian Patient Safety Institute, 2011). In addition, patient care errors are rarely the result of just one person’s mistake, but, instead, often reflect predictable human failings in the context of poorly designed systems. Despite current research into human factors as direct contributors to patient care errors, many of our complex medical procedures are based on perfect memory, even though we humans are prone to short-term memory loss (Frank, Hughes, & Brian, 2008).

In health care education, students must have the knowledge, skills, attitudes, and experience to be able to anticipate, identify, and manage situations that place patients at risk. To become competent in clinical skills, students practice in the classroom and laboratory, and then apply what they have learned to practice with supervision and support in the clinical setting. However, students today are often faced with less than optimal clinical exposure and assessment to develop the expertise and experience they need to be fully competent by graduation. Furthermore, inter-professional teamwork creates shared patient care environments, where many disciplines will care for patients and their conditions, and patient information and care management moves frequently among health care providers. Successful patient treatment is reliant on many different health care providers and their skill sets, and each discipline teaches clinical skills differently. The lack of consistency in training and in the use of the latest evidence-based research in health care education makes it challenging to ensure safe care.

These issues contribute to unsafe care and preventable medical errors. In the delivery of health care and professional health care practice, it is no longer acceptable that preventable errors continue to take place in modern-day health care. Health care providers need a method to improve patient care, and standardization of processes and approaches, such as is provided by practice guidelines and checklists, will contribute to the development of safer patient care (Canadian Nurses Association, 2004).

In reviewing incidents and preventable errors, significant factors, including human factors, have been identified, and strategies have been introduced to reduce the likelihood of errors and to create a safe standard of care. The creation of guidelines for the execution of processes will not change culture, but can encourage us to find a level of practice that contributes to standardizing safe care and helps us deal with our human failings as we try to always perform perfectly in a complex environment. Change should be focused on creating robust safety systems. Among these, the point-of-care checklist has been proven to be a safe strategy, and is now becoming more common in health care (Frank, Hughes, & Brien, 2008).

Use of Checklists

Checklists are the predominant format used in this resource, following the work of Dr. Atul Gawande, described in his book The Checklist Manifesto: How to Get Things Right (2010). Dr. Gawande believes that although the modern world has given us knowledge and experience, avoidable medical errors continue to occur. Dr. Gawande posits that the reason for this is simple: the volume and complexity of health care today has exceeded our ability as individuals to properly deliver it when caring for people consistently, correctly, and safely. He argues that we can do better by using the simplest of methods: the checklist. The most often-cited example of Dr. Gawande’s work is a simple surgical checklist from the World Health Organization that has been adopted in more than 20 countries as a standard of care and has been heralded as “the biggest clinical invention in thirty years” (The Independent, cited in Gawande, 2010). Just one example of its success comes from the United States: when the State of Michigan began using a checklist for central lines in its intensive care units, the infection rate dropped 66% in three months. In 18 months, the checklist saved an estimated $175 million and 1,500 lives (Shulz, 2010). Checklists allow for complex pathways of care to function with high reliability by giving the users an opportunity to review their actions individually and with others, and to proceed in a logical, safe manner.

This open educational resource (OER) was developed to ensure best practice and quality care based on the latest evidence, and to address inconsistencies in how clinical health care skills are taught and practiced in the clinical setting. The checklist approach aims to provide standardized processes for clinical skills and to help nursing schools and clinical practice partners keep procedural practice current.

How to Use This Book

This book should be used in conjunction with existing courses in any health care program. This book is not intended to replace core resources in health care programs that provide comprehensive information concerning diseases and conditions. An understanding of medical terminology, human anatomy, physiology, and pathophysiology is a required asset to use this book effectively. The development of technical skills is based on the knowledge of, practice to achieve proficiency in, and attitudes related to the skill, and an awareness of how our roles affect our patients and other health care professionals. This book contributes to enhancing safer care for patients by outlining evidence-based practices, and looking beyond just the technical skill to understanding the types of expertise and knowledge required to decrease adverse events. In each of the 89 checklists throughout this book (and summarized in Appendix 2), rationale for each step is provided in the form of Additional Information.

Each skill/procedure is covered in a chapter that has learning outcomes, a brief overview of the relevant theory, checklists of steps for procedures with the rationale behind each step of the process, and a summary of key takeaways. Photographs and diagrams (referred to as figures) relevant to the topic are included. The checklists are extendable across all health care professions and are relevant to nursing (RN, NP, LPN, RPN, and CA), allied health, and medical students. They also provide an opportunity for further sharing and collaboration among health care professionals. Students will find this resource valuable at the point of care to reduce the risk of adverse events and to provide a deeper understanding of safety considerations, infection control practice, injury prevention, and the value of consistency in clinical processes. Some key terms are set in bold  and explained in the Glossary in Appendix 1.

Our hope is that not only will the checklists in this resource provide clear and concise guidelines for performing clinical skills in the health care setting, but that they will also improve patient safety and quality of care.

Note: For the sake of consistency, the term patient and client are used interchangeably to refer to any person who is being cared for in the health care setting.

Suggested Online Resources

Patient Safety

1. BC Patient Safety and Quality Council. This website provides information on the latest initiatives from the BC Ministry of Health to improve clinical issues such as preventing (Deep Venous Thrombosis) DVTs; introducing the 48/6 model of care; improving hand hygiene; creating pathways of care for conditions such as heart failure, stroke, and (transient ischemic attacks) TIAs; reconciling medication; caring for the critically ill; and developing the surgical checklist.

2. Canadian Patient Safety Institute (CPSI). This website provides access to resources, toolkits, events, education, and conferences related to making patient safety happen in health care. It also reviews the latest initiatives.

3. Institute for Healthcare Improvement Open School. Free online courses about health care leadership, patient safety, improving capability, improving patient- and family-centred care, and population health can be found on this resource.

4. Institute for Safe Medication Practices. This is an excellent resource for the latest safety alerts and ways to advance safe administration of medication.

Interprofessional Education (IPE)

1. University of British Columbia Interprofessional Practice Education. This resource provides online modules for students to review strategies to work effectively across disciplines.

2. Institute for Healthcare Improvement (IHI). Free resources and strategies on how to improve health and healthcare around the world are listed on this website. It also offers free online courses to enhance teamwork, communication, and other topics related to safety in health care.

References

Baker, G., Norton, P., Flintoff, V. et al. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. CMAJ 170:1678-1686.

Butt, A. R. (2010). Medical error in Canada: Issues related to reporting of medical error and methods to increase reporting. McMaster University Medical Journal, 7(10), 15-18.

Canadian Nurses Association and University of Toronto Faculty of Nursing. (2004). Nurses and patient safety: A discussion paper. Retrieved on Aug 26, 2015, from http://www.cna-aiic.ca/~/media/cna/files/en/patient_safety_discussion_paper_e.pdf?la=en

Canadian Patient Safety Institute. (2011). Canadian framework for teamwork and communication. Literature review, needs assessment, evaluation of training tools and expert consultations. Retrieved on Aug 26, 2015, from http://www.patientsafetyinstitute.ca/en/toolsResources/teamworkCommunication/pages/default.aspx

Frank, J. R., & Brien, S. (eds.) on behalf of the Safety Competencies Steering Committee. (2008). The safety competencies: Enhancing patient safety across the health professions. Ottawa, ON: Canadian Patient Safety Institute.

Gawande, A. (2010). The checklist manifesto: How to get things right. New York City, NY: Metropolitan Books.

Hughes, R. G. (2008). Nurses at the “sharp end” of patient care. Chapter 2 in Patient safety and quality: An evidence-based handbook for nurses. Retrieved on Aug 26, 2015, from http://www.ncbi.nlm.nih.gov/books/NBK2672/

Shulz, K. (2010). Check, please: Atul Gawande’s The Checklist Manifesto. Retrieved from Huffington Post, Retrieved on Aug 26, 2015, from http://www.huffingtonpost.com/kathryn-schulz/check-please-atul-gawande_b_410507.html

4

Disclaimer

The field of health care is constantly changing and evolving. Procedures and policies in schools and health care agencies will change in accordance with research and practice. This resource will require updates to remain in accordance with these changes, but the authors do not assume responsibility for these updates.

Health care professionals must ensure that they have a strong foundation of knowledge in medical conditions and surgical procedures related to clinical skills and techniques before using this resource to guide their practice. Health care professionals should always put agency policy above the information in this resource and be mindful of their own safety and the safety of others. Any health care professional using this resource should do so in the appropriate environment and under the supervision of other relevant health care professionals, in accordance with their governing professional body and within their scope of practice.

It is the responsibility of any health care professionals using this book to take all appropriate safety precautions and to determine best practice unique to the patient and the context of the situation. The authors do not assume responsibility for any injury or damage to persons or property pertaining to the use of the material and information in this resource.

I

Chapter 1. Infection Control

1

1.1 Introduction

In healthcare, the use of effective and safe infection prevention and control practices is everyone’s responsibility. Infection prevention and control guidelines are mandated in hospitals to protect patients, healthcare personnel, and families from the transmission of organisms that cause infections. This chapter will review the principles of infection prevention and control practices, and the use of additional precautions and personal protective equipment to control and prevent the spread of infection in acute healthcare settings. The chapter also will explore surgical asepsis, the principles of sterile technique, and procedures related to sterile technique in the operating room and during invasive procedures.

Learning Outcomes

  • Define infection prevention and control practices.
  • Explain what is meant by chain of infection.
  • Describe routine practices for infection prevention and control.
  • Describe what is meant by point of care risk assessment.
  • Differentiate between the three types of additional precautions: contact, airborne, and droplet.
  • Explain how and when to use additional precautions and personal protective equipment (clean gloves, gown, face shield, eye protection, N-95 mask, procedure mask).
  • Define blood or body fluid exposure and the steps to take if exposed.
  • Explain six or more principles of asepsis.
  • Describe when surgical asepsis and sterile technique are used.
  • Demonstrate the following skills: hand hygiene with soap and water, hand hygiene with alcohol based hand rubs (ABHR), preparing a sterile field, application of sterile gloves, and donning and doffing of PPE.

2

1.2 Infection Prevention and Control Practices

Infection prevention and control (IPAC) practices are evidence-based procedures and practices that can prevent and reduce disease transmission, and eliminate sources of potential infections (PIDAC, 2012). When used consistently, IPAC practices will prevent the transfer of healthcare-associated infections (HAIs) in all healthcare settings. HAIs, also known as nosocomial infections, are infections that occur in any healthcare setting as a result of  contact with a pathogen that was not present at the time the person infected was admitted (World Health Organization, 2009a).

Two types of techniques are used to prevent infection in the hospital setting. The first, medical asepsis or clean technique, has been used in the past to describe measures for reducing and preventing the spread of organisms (Perry, Potter & Ostendorf, 2014). The second, sterile technique, also known as sterile asepsis, is a strict technique to eliminate all microorganisms from an area (Perry et al., 2014). When a patient is suspected of having or is confirmed to have certain pathogens or clinical presentations, additional precautions are implemented by the healthcare worker in addition to routine practices (PIDAC, 2012). These additional precautions are based on how an infection is transmitted, such as by contact, droplet, or air. Additional precautions use personal protective equipment (PPE), such as gowns, eyewear, face shields, and masks, along with environmental controls to prevent transmission of infection.

To reduce and prevent the spread of HAIs, a system of recommended IPAC routine practices are to be used consistently with all patients at all times in all healthcare settings (Public Health Agency of Canada, 2012b). The principles of routine practices are based on the premise that all patients are potentially infectious, even when asymptomatic, and IPAC routine practices should be used to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or soiled items (PIDAC, 2012).

To learn the steps for routine practices, see Checklist 1.

Checklist 1: Routine Practices

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Routine practices must be used by all healthcare professionals, at all times, with all patients/residents/clients in all healthcare settings. Routine practices will prevent transmission of microorganisms from patient to patient, patient to staff, staff to patient, and staff to staff. 
  • The presence of a pathogen does not predict the onset of an infection. The chain of infection must be present. If the chain of infection is broken, an infection will not occur. Routine practices are used to break or minimize the chain of infection.
  • Be aware of factors that increase a patient’s risk of becoming colonized or infected in the hospital. Increased acuity, advanced age, use of invasive procedures, immuno-compromised state of the patient, greater exposure to microorganisms, and an increased use of antimicrobial agents and complex treatments are common risk factors.
  • Reduce patient susceptibility to infection by encouraging immunizations, providing adequate rest and nutrition, and protecting the body’s defences from infection (cover open wounds, keep drainage systems closed and intact, maintain skin integrity). 
  • HAIs can cause symptoms ranging from asymptomatic colonization to septic shock and death, resulting in increased suffering for patients and increased healthcare costs for Canadians. Ensure additional precautions guidelines are followed for all suspected and confirmed cases of infections and communicable diseases.
  • The most common sites for HAIs are the urinary and respiratory systems, and central line-associated bloodstream infections. Consider practices that will reduce infections related to these systems.
  • The most common types of HAIs in Canada are methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and Clostridium difficile (CDI). Ensure all healthcare providers and visitors follow the additional precautions policies. 

Steps

 Additional Information

1. Complete a risk assessment to determine your need for PPE (gown, clean gloves, mask, face shield, or eyewear).

The Public Health Agency of Canada (PHAC) provides an algorithm for Point of Care risk assessment 

Consider: Will your face, hands, skin, mucous membranes, or clothing be exposed to blood, excretions, or secretions by spray, coughing, or sneezing?

Will you have contact with the patient’s environment / surfaces?

Is an infection or communicable disease suspected or confirmed?

2. Perform hand hygiene (hand washing) following hospital policy. Hand hygiene is considered the most important and effective measure to prevent HAIs.

HAIs are most commonly spread by the hands of healthcare workers, patients, and visitors. Healthcare workers, patients, and visitors spread about 80% of all HAIs.

Always perform hand hygiene after using the washroom, coughing, or sneezing, and before and after eating.

Using an alcohol-based hand rub (ABHR) is the recommended method for hand hygiene if hands are not visibly soiled.

3. Follow proper cleaning or disinfecting procedures of patients and the environment (room etiquette). These environmental controls will control the site or source of microorganism growth.

 

Dispose of soiled linens and dressings in appropriate receptacle bin.

Avoid contact of soiled item with uniform.

Clean contaminated objects and sterilize or disinfect equipment and patient rooms according to agency policy.

Discard any item that touches the floor.

Control sources of wound drainage and body fluids; change soiled dressings.

Avoid shaking bed linen or clothes; dust with a damp cloth as required. Microorganisms can be expelled through the air and inhaled by patients and healthcare workers.

Provide all persons with their own linen and personal items.

Place syringes in designated puncture-proof containers.

Keep table surfaces dry and clean.

Empty and dispose of drainage containers as per agency policy.

4. Follow respiratory etiquette. Wear a mask if coughing or sneezing.

Wear a mask if suffering from a respiratory condition, and consider staying home.

Avoid talking, sneezing, or coughing over open wounds and sterile dressings.

Practise coughing or sneezing into your upper arm, not your hands.

Follow hospital policies related to creating healthy workplaces.

Do not come to work ill or with symptoms of a communicable disease (flu or cold) that puts co-workers or patients at risk.

5. Wear clean gloves for appropriate activities based on a risk assessment. Use clean gloves when handling all blood and body fluids. Follow recommendations for assessing each situation and the need for clean gloves.

Improper glove use has been linked to the transmission of microorganisms. Do not wear gloves for activities that do not pose a risk, such as feeding or taking blood pressure.

Clean gloves are task specific and for single use only.

Handle all blood, body fluids, and laboratory specimens as if infectious.

Always perform hand hygiene after taking off clean gloves to reduce the potential of contamination from pathogens on gloves.

6. Use additional precautions guidelines for suspected or known infections or communicable diseases. Use PPEs based on mode of infection transmission (contact, droplet, or airborne). Follow agency guidelines essential to prevent and reduce transmission of infections.

Single rooms, cohorting (placing patients with the same infections in the same room if a private room is not available), restricting visitors, and implementing additional environmental controls may be required.

Provide instruction and signage for appropriate use and disposal of PPE for visitors, patients, and all healthcare workers.

Remove PPE immediately after single use and perform hand hygiene.

7. Do not eat or drink in the patient / client, or resident areas. Eating and drinking increases the risk of transmission of infection between healthcare providers and patients.
8. Use avoidance procedures and actions to minimize the risk of infection transmission. If a patient has uncontrolled diarrhea, wear a gown when changing linen to prevent contamination of clothing and hands.

If a patient is coughing, sit next to, rather than in front of, the patient when talking to that patient.

Data sources: CDC, 2007, 2014; Perry et al., 2018; PIDAC, 2012; PHAC, 2012b, 2013; WHO, 2009a

Critical Thinking Exercises

  1. Name six elements in the chain of infection.
  2. Identify two things that can be done at each of the points in the chain of infection to break the chain.
  3. What types of patients are at an increased risk for an HAI?
  4. How can healthcare providers reduce patient susceptibility to infection?

3

1.3 Hand Hygiene and Non-Sterile Gloves

Hand Hygiene

Hand hygiene is the most important part of practice for healthcare workers and is the single most effective way to stop the spread of infections; failure to properly perform hand hygiene is the leading cause of HAIs and the spread of multi-drug-resistant organisms (MDROs) (BC Centre for Disease Control, 2014; WHO, 2009a). Hand hygiene is a general term used to describe any action of hand cleaning and refers to the removal or destruction of soil, oil, or organic material, as well as the removal of microbial contamination acquired by contact with patients or the environment. Hand hygiene may be performed using an alcohol-based hand rub (ABHR) or soap and water. A surgical hand scrub is also a method of hand hygiene (WHO, 2009a).

To break the chain of infection, there are five key moments at which to perform hand hygiene when working in healthcare, as outlined in Checklist 2 and illustrated in Figure 1.1.

   Checklist 2: Five Key Moments in Hand Hygiene

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • If contact dermatitis occurs, use soap and water for hand hygiene.
  • Instruct patients and family on the importance of hand hygiene, proper technique, and ways to incorporate routines into everyday practice.
  • Certain practices can increase the risk of skin irritation and should be avoided. For example, washing hands regularly with soap and water immediately before or after using an alcohol-based product is not only unnecessary but may lead to dermatitis.
  • Always wash hands whenever in doubt.

Key Moments

 Additional Information

1. Before initial contact with a patient, client, resident, or the environment. Before touching a patient (e.g., feeding, toileting, or personal care)

Before touching the patient’s environment

Before adjusting an IV rate

Before taking a pulse or blood pressure

2. Before any clean (routine) or aseptic (sterile) procedure Before applying clean or sterile gloves

Before performing a sterile dressing change

Before feeding a patient

Before performing oral or dental care

Before inserting eye drops

Before inserting Foley catheter

Before preparing medication

3. After blood or body fluid risk or exposure After contact with body secretions, mucous membranes, or non-intact skin

After glove removal (clean or sterile gloves)

After handling waste (urine, drainage, wound care)

After wound care or a sterile procedure

When moving from a contaminated area on the body to a non-contaminated area

4. After contact or touching the patient, client, or resident After taking a blood pressure or pulse, touching a urinary catheter, or feeding or dressing a patient
5. After contact with the patient’s, client’s, resident’s environment After touching a bed table or bathroom light

After touching personal toiletries

After touching walkers or wheelchairs

After touching electronic IV devices

After taking blood pressure or pulse

After changing bed linen

Data source: Kampf & Loffler, 2003; WHO, 2009a, 2009b
5 moments in hand hygiene
Figure 1.1 Five moments in hand hygiene from the World Health Organization

Safety Alert: Factors that Reduce Hand Hygiene Effectiveness

How to Wash Hands: Types of Hand Hygiene

Two types of hand hygiene are commonly used in the healthcare setting: hand hygiene with an alcohol-based hand rub (see Figure 1.2) and hand hygiene with soap and water.

Figure 1.2 Alcohol-based hand rub

Alcohol-based hand rub (ABHR) is a product containing 60% to 90% alcohol concentration and is recommended for hand hygiene in healthcare settings (CDC, 2012). ABHR is the preferred method of hand hygiene and is more effective than washing hands with soap and water (WHO, 2009a). ABHRs:

See Checklist 3 for the steps to take when washing hands with ABHR.

Checklist 3: Hand Hygiene with ABHR

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Do not use in combination with soap and water. This practice may increase skin irritation.
  • Use ABHR that contains emollients (oils) to help reduce skin irritation and overdrying.
  • Allow hands to dry completely before initiating tasks or applying clean or sterile gloves.
  • ABHR may be used for all five moments in hand hygiene (see Checklist 2) as long as hands are not contaminated or visibly soiled.
  • DO NOT use ABHR if patient is suspected to have or confirmed with Clostridium difficile, norovirus, or Bacillus anthracis. ABHR will not kill spore-forming pathogens. 

Steps

 Additional Information

1. Remove all jewellery on hands. Apply 1 to 2 pumps of product into palm of dry hands.
Remove Jewellery
Remove jewellery

Product should not be applied to wet hands, as this will dilute the product.

Enough product should be applied to thoroughly wet hands and fingers (approx. 30 ml) for the entire procedure of 20 to 30 seconds.

Apply ABHR onto hands
Apply ABHR onto hands

Always follow the manufacturer’s guidelines.

2. Rub hands together, palm to palm. Rubbing hands together ensures palm surfaces are covered by the product.
DSC_1584
Rub alcohol over entire surface of palms
3. Rub the back of the hands. Rubbing the back of the hands allows all surfaces of the fingers to be exposed to the product.
Rub back of hands
Rub back of hands
4. Rub the alcohol between all the fingers to cover all the fingers. Rubbing between the fingers allows all surfaces of the hands to be exposed to the product.
DSC_1588
Rub between the fingers
5. Press fingertips into the palm of opposing hand and rub back and forth. Pressing fingertips into opposing palms and rubbing ensures fingertips and nails are exposed to the cleaning product. Nails harbour more bacteria than do hands.
DSC_1591
Clean with ABHR under the fingernails
6. Rub each thumb in a circle in the palm of the opposite hand. Rubbing each thumb provides complete coverage of the product on the thumb.
DSC_1598
Clean the surface of thumb
7. Rub hands together until they are dry. Do not use a paper towel to dry hands. Rubbing hands together provides adequate time for the alcohol to dry. The minimum time required for proper rubbing technique when using ABHR is 20 to 30 seconds.
DSC_1584
Rub hands until dry
8. Hands are now safe to use.
DSC_1595
Clean hands
Data sources: CDC, 2012; PIDAC, 2012; PHAC, 2012b; WHO, 2009a, 2009b

Hand Hygiene with Soap and Water

Hand hygiene with water requires soap to dissolve fatty materials and facilitate their subsequent flushing with water. Soap must be rubbed on all surfaces of both hands followed by thorough rinsing and drying. Water alone is not suitable for cleaning soiled hands (WHO, 2009a). The entire procedure should last 40 to 60 seconds and should use soap approved by the health agency. See the steps in Checklist 4.

    Checklist 4: Hand Hygiene with Soap and Water

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Always wash hands with soap and water if hands are visibly dirty or soiled.
  • When working with patients where Clostridium difficile (CDI), norovirus, or Bacillus anthracis is suspected or confirmed, soap and water must be used. CDI can remain dormant on surfaces for long periods of time. 
  • Always use soap and water if hands are exposed to blood or body fluids.
  • Multi-step rubbing techniques using soap and water are required to promote coverage of all surfaces on hands. Friction and rubbing are required to remove oil and debris from hands.

Steps

 Additional Information

1. Remove all jewellery. Wet hands with warm water.
Remove jewelry
Remove jewellery

A comfortable temperature of water should be used. Hot water may damage skin.

Regulating water temperature
Regulate water temperature
2. Apply 1 to 2 pumps of soap. Enough soap should be used to lather the palms, back of hands, fingers, and thumbs.
Dispense soap
Dispense soap
3. Lather soap and rub palms together. Ensure all surfaces of the palms are covered with soap, using friction to remove debris and oil.
Lather hands with soap and water
Lather hands with soap and water
4. Rub in between fingers and around fingers. Ensure all surfaces of the fingers are covered with soap, using friction to remove debris and oil.
Rub hands to remove debris and oil
Rub hands to remove debris and oil
5. Rub the back of each hand with the palm of the opposite hand. Ensure all surfaces on the back of the hands are covered with soap, using friction to remove debris and oil.
Rub the back of the hands
Rub the back of the hands
6. Press and rub fingernails and fingertips into the palm of the opposite hand. Ensure all surfaces around the fingertips are covered with soap, using friction to remove debris and oil.
Clean tips of fingers and underneath nailbeds
Clean tips of fingers and underneath nailbeds
7. Rub each thumb in a circle with the palm of the opposite hand. Ensure all surfaces around the thumbs are covered with soap, using friction to remove debris and oil.
Clean around the thumb up to the wrist on both hands
Clean around the thumb up to the wrist on both hands
8. Rinse hands under water by keeping fingers pointing downward toward the drain. Rinsing in this way allows the oil and debris to be washed off the hands and down the drain.
Rinse soap and water off hands
Rinse soap and water off hands
9. Pat hands dry using clean paper towel. Use a gentle action to prevent skin irritation.
Dry hands
Dry hands
10. Using a clean paper towel, turn off faucet. Using a paper towel prevents re-contamination of hands by touching dirty faucet handles.
Turn off facet with dry paper towel
Turn off faucet with dry paper towel
11. Hands are now safe to use.
Clean hands
Clean hands
Data source: Accreditation Canada, 2013; CDC, 2014; PHAC, 2012a; WHO, 2009a

Non-Sterile (Clean) Gloves

Both hand hygiene and clean glove use are strategies to prevent transmission of infections through hand contact. In the context of patient care, it makes sense to think of glove use and hand hygiene as complementary strategies to prevent transmission of pathogens. Gloves are critical to prevent the transmission of organisms when hand hygiene alone is not enough in an outbreak such as Clostridium difficile or the norovirus, or when a patient has a suspected or known pathogen. Studies have shown that gloves reduce transmission of microbes from the hands of healthcare workers (PIDAC, 2012).

Non-sterile gloves are single use and should be applied:

Non-sterile gloves should be removed:

See Checklist 5 for steps on how to apply and remove non-sterile gloves.

    Checklist 5: Applying and Removing Non-Sterile Gloves

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Hands must be clean and dry before putting on gloves. Gloves do not replace the need for hand hygiene.
  • Hand hygiene must be performed every time gloves are removed. Gloves are not completely free of leaks or 100% tear-proof, and hands may become contaminated when gloves are removed. 
  • Gloves are for single patient use and must be removed after caring for one patient. Reuse of gloves has been associated with transmission of antibiotic-resistant organisms.
  • Change or remove gloves if moving from a contaminated site to a non-contaminated site on the same person or if touching the environment.
  • Wear gloves that fit properly. Different sizes are available.
  • Gloves must be removed immediately and discarded in a waste bin after the activity for which they were used and before exiting a patient’s environment.
  • Gloves are not required for healthcare activities where contact is limited to intact skin, such as taking blood pressure.
  • Indiscriminate or improper glove use (e.g., wearing gloves all the time) has been linked to transmission of pathogens.
  • Gloves should fit snugly around wrists and hands for use with a gown to provide a better skin barrier.

How to Don (apply) Non-Sterile Gloves

Steps

 Additional Information

1. Perform hand hygiene.
Hand hygiene with ABHR
Hand hygiene with ABHR
2. Select the appropriate size of non-sterile gloves. Remove gloves one at a time out of the box, touching only the top of the cuff.
Remove gloves from box
Remove gloves from box
3. Put hand through opening and pull up to the wrist.
Apply first glove
Apply first glove
4. Repeat procedure with the second hand.
Apply second glove
Apply second glove
5. Adjust gloves to cover wrists or gown as required.  Prevents the contamination of the wrists.
6. Complete care as required.
Non-sterile gloved hands
Non-sterile gloved hands

How to Doff (remove) Gloves

Steps

Additional Information

1. Grasp glove on the outside about 1/2 inch below the cuff (edge of the glove opening). Do not touch the wrist with the other hand.
Grasp glove on the outside 1/2 inch below the cuff
Grasp glove on the outside 1/2 inch below the cuff
2. Pull down glove, turning it inside out. Hold the inside-out glove in the gloved hand.
Pull glove off inside out
Pull glove off …
... inside out
… inside out
3. Gather the inside-out glove in the gloved hand.
Gather inside out glove in remaining gloved hand
Gather inside-out glove in remaining gloved hand
4. Insert finger of the bare hand under the cuff of the gloved hand.
Insert finger under cuff of gloved hand
Insert finger under cuff of gloved hand
5. Pull down the glove until it is inside out, drawing it over the first glove.
Remove second glove
Remove second glove
6. Discard gloves in a garbage container. This step reduces the spread of microorganisms.
Discard used non-sterile gloves
Discard used non-sterile gloves
7. Perform hand hygiene. This step reduces the spread of microorganisms.
Hand hygiene with ABHR
Hand hygiene with ABHR
Data sources: Braswell & Spruce, 2012; PIDAC, 2012; Poutanen et al., 2005; PHAC, 2012a; WHO, 2009a

Latex Allergies and Non-Sterile (Clean) Glove Use

A latex allergy is a reaction to the proteins in natural rubber latex (American Academy of Allergy, Asthma and Immunology, 2014). When people come in contact with latex, an allergic reaction may occur. Most reactions are mild (asthma-like symptoms or contact dermatitis), but there are some rare severe cases (reactions). Many hospitals have moved away from using latex gloves, but latex is commonly used in many healthcare products such as IV tubing, urinary catheters, syringes, dressings, and bandages. People at risk for developing a latex allergy are:

Note that powdered latex gloves have also been associated with latex allergies. If an allergy to latex exists, the best treatment is to avoid latex and use a medical alert bracelet to inform others of the allergy (PIDAC, 2012).

Critical Thinking Exercises

  1. Name four factors that decrease the effectiveness of hand hygiene.
  2. What are two ways to reduce or prevent skin irritation with hand hygiene or non-sterile (clean) glove use?

4

1.4 Additional Precautions and Personal Protective Equipment (PPE)

Certain pathogens and communicable diseases are easily transmitted and require additional precautions to interrupt the spread of suspected or identified agents to healthcare providers, other patients, and visitors (PIDAC, 2012). Additional precautions are used in addition to routine precautions and are defined by how a microorganism is transmitted (Perry et al., 2014).

Point of Care Risk Assessment (PCRA) is the first step in routine practices. As such healthcare workers should be doing this with all patients for all care at all times. It involves assessing the infection risk posed to themselves and others by the patient, a procedure or a situation. Personal protective equipment (PPE) is chosen based on that risk (Vancouver Coastal Health, 2017).

Types of Additional Precautions

There are three categories of additional precautions: contact precautions, droplet precautions, and airborne precautions (CDC, 2007).

Contact precautions are are the most common type of additional precautions. They are used in addition to routine practice for patients who are known or suspected to be infected with microorganisms that can be transferred by direct (touching) or indirect (shared equipment) contact. Types of organisms in this category are antibiotic-resistant organisms (AROs) such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta-lactamase (ESBL), Clostridium difficile (CDI), carbapenemase-producing organisms (CPO), diarrhea, and scabies. AROs are also known as multi-drug-resistant organisms (MDROs).

Droplet precautions are used in addition to routine practices for patients who are known or suspected to be infected with microorganisms that are spread through the air by large droplets. Types of organisms and unconfirmed conditions in this category include mumps, influenza, vomiting of unknown cause, norovirus, and unconfirmed cough.

Airborne precautions are used in addition to routine practices for patients who are known to have or are suspected of having an illness that is transmitted by small droplet nuclei that may stay suspended in the air and be inhaled by others. These particles can remain infectious for a long period of time when spread through the air. Types of organisms in this category include tuberculosis (TB), measles, chicken pox (varicella), disseminated zoster, and severe acute respiratory syndrome (SARS).

Special considerations:

Tables 1.1, 1.2, and 1.3. summarize the three categories of additional precautions.

Table 1.1 Contact Precaution Guidelines

PPE

Private Room

Visitors

Patient Transport

Cleaning

Gown, gloves Private room preferred or cohort patients.

Must have own dedicated equipment.

Gown and gloves must be worn if providing direct care.

Must perform hand hygiene before and after care.

Must not go into other patient rooms.

Patient: none required

Staff: gown and gloves

Additional daily room cleaning may be required.

 

Data source: PIDAC, 2012; PHAC, 2013; Siegal, Rhinehart, Jackson, & HICPAC, 2007

Table 1.2 Droplet Precautions

PPE

Private Room

Visitors

Patient Transport

Cleaning

Gloves, gown, and a surgical mask if within two metres of the patient Private room preferred or cohort.

Must have own dedicated equipment.

 

Gown, gloves, surgical masks, and eye protection are worn for all activities within two metres of the patient.

The patient must wear a surgical mask when leaving the room.

The door may remain open.

Strict adherence to hand hygiene must be observed.

Gloves, gown, and surgical mask must be worn  if providing direct care. Must perform hand hygiene before and after care.

Visitors may not go into other patient rooms.

Patient: gown, surgical mask Additional daily room cleaning may be required.
Data source: PIDAC, 2012; PHAC, 2013; Siegal et al., 2007

Table 1.3 Airborne Precautions

PPE

Private Room

Visitors

Patient Transport

Cleaning

Must wear N95 respirator prior to entering room.

Strict adherence to hand hygiene.

Must remove N95 respirator after exiting the room.

No immune-compromised persons to enter room. Care providers should have current vaccines.

Yes.

Must have a negative pressure room.

Must have own dedicated equipment.

Keep the door closed whether or not the patient is in the room.

The room should have bathroom facilities.

The room must be a single room, preferably one that is under negative pressure. When a negative pressure room is unavailable, refer to your health authority policy to determine whether a transfer to another facility is mandated.

Gloves, gown, and surgical mask required if providing direct care.Must perform hand hygiene before and after care.

Must not go into other patient rooms.

Patient: must wear surgical mask

Staff: N95 mask

Additional daily room cleaning may be required.
Data source: PIDAC, 2012; PHAC, 2013; Siegal et al., 2007

Personal Protective Equipment (PPE)

Additional precautions require the use of personal protective equipment (PPE), which is equipment or clothing worn by staff to prevent the transmission of infection from patient to staff or to family member (PIDAC, 2012). All PPE must be applied and removed in a specific order to ensure the skin, nose, mouth, and eyes are covered to prevent transmission of infection to healthcare providers. Depending on the type of additional precaution or risk assessment, a gown, goggles, face shield, and mask (surgical or N95) may be used during patient care. Refer to Checklist 6 for steps to take when donning (putting on) PPE.

    Checklist 6: Donning PPE

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • The selection of PPE is based on the nature of the interaction with the patient and the likelihood of transmission of infectious agents.
  • PPE should be put on just prior to the interaction with the patient and should be removed immediately after the interaction, followed by hand hygiene.
  • Donning of PPE is usually done outside the patient’s room.
  • Patients may feel depressed or lonely when isolated in a room or experiencing decreased contact with healthcare providers. Support for individuals on isolation must be provided. Conversely, some patients may appreciate the privacy of an individual room.

Steps

 Additional Information

1. Remove rings, bracelets, and watches. Perform hand hygiene. This prepares hands for direct patient care.
Perform hand hygiene
Perform hand hygiene
2. Apply waterproof long-sleeved gown. Tie the neck and waist strings. Waterproof gown prevents any potential cross-contamination from blood or body fluids onto forearms and body.
Apply water proof gown
Apply waterproof gown
3. Apply mask. Remember different masks are required for different situations. Ensure the fit is secure with no air leaks. Secure the metal band around the nose and pull mask over chin as required. Wearing a poor-fitting mask is the number one reason for exposure to pathogens for healthcare providers.

Masks should be worn if provider is within two metres of a coughing or sneezing patient or if there is a potential for spray of secretions or excretions.

Surgical mask (L) and N95 mask (R)
Surgical mask (left) and N95 mask (right)

Replace mask if it becomes wet or soiled.

Apply mask
Apply mask
4. Apply goggles or face shield. Goggles or a face shield prevents accidental exposure to eyes, nose, and mouth. Goggles can be placed on top of eyeglasses.

Prescription glasses are not an alternative to goggles as they do not protect the entire eye.

Applying goggles
Apply goggles
5. Apply non-sterile gloves over top of the cuff of the gown. Non-sterile gloves ensure complete coverage of skin on arms for direct patient care.
apply non-sterile gloves over top of sleeves
Apply non-sterile gloves over top of sleeves
Data source: Barratt, Shaban, & Moyle, 2011; PIDAC, 2012; PHAC, 2012b

See Checklist 7 for steps on how to doff (or remove) PPE.

    Checklist 7: Doffing PPE

Disclaimer: Always review and follow your agency policy regarding this specific skill.

Steps

 Additional Information

1. Remove gloves. Grasp outer edge of glove by wrist and peel away from hand, rolling the glove inside out. Roll it into a ball in gloved hand.

With the bare hand, reach under the second glove and gently peel down off the fingers.

Place bare finger under gloved hand to avoid contamination from glove
Place bare finger under glove to avoid contamination from glove

Drop glove into garbage bin.

Always perform hand hygiene after removing gloves. Gloves are not tear- or leak-proof. Hands may have been contaminated upon removal of the gloves.

2. Perform hand hygiene. Use soap and water if hands are visibly dirty.
Perform hand hygiene
Perform hand hygiene
3. Remove gown. Remove gown in a manner that does not contaminate clothing. Starting at the neck ties, pull the outer (contaminated) part forward and, turned inward, roll into a ball. Discard in appropriate receptacle bin.
Remove gown
Remove gown
4. Perform hand hygiene. Always perform hand hygiene after removing gown. Hands may have been contaminated upon removal of the gown.
Perform hand hygiene
Perform hand hygiene
5. Remove eye protection or face shield. Arms of goggles and the headband on the face shield are considered clean. Handle these only by the sides. The front of the face shield or goggles is considered contaminated. Dispose them according to agency policy.
Remove goggles
Remove goggles

Ensure you are at least two meters from the patient when removing eyewear.

6. Remove mask or N95 respirator. Ties, earlobe loops, or straps are considered clean and may be touched. If tied, remove bottom tie first, then top tie. Remove ear loops or straps by leaning forward to allow the mask to slip off your face.

Masks are removed outside the patient room

Dispose of the mask in the garbage bin.

Remove mask
Remove mask
7.  Perform hand hygiene. This step reduces the transmission of microorganisms.
Perform hand hygiene
Perform hand hygiene
Data source: Barratt et al., 2011; Perry et al., 2014; PHAC, 2012b; Siegal et al., 2007
Watch the video Donning and Doffing PPE by Renée Anderson & Wendy McKenzie Thompson Rivers University
Please note the CDC offers another option for doffing PPE. See How to Remove PPE Example 2 on page 3   https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

Blood or Body Fluid (BBF) Exposure

A blood and body fluid (BBF) exposure is defined as an exposure to potentially infectious body fluids or blood through the following methods: a puncture wound by a sharp object or needle (percutaneous exposure), from a body fluid/blood splash onto your mucous membranes (permucosal exposure) or exposure through eczema, an open wound/skin or scratch (non-intact skin exposure) (BCCDC, 2015).

Post-exposure management is only required when (1) percutaneous, permucosal, or non-intact skin is exposed to a BBF; (2) the exposure is to blood or potentially infectious body tissue or fluid; (3) the source is considered potentially infectious (e.g., patient is part of a high-risk group, exposure occurred in a high-risk setting, or patient has a positive test); and (4) the exposed person is considered susceptible to HIV, hepatitis B, or hepatitis C. Checklist 8 explains what to do if exposed.

    Checklist 8: BBF Exposure

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Evidence shows that antiretroviral therapy can reduce the transmission of HIV by 86%.
  • The risks and benefits of the post-exposure immunoprophylaxis should be discussed and appropriate recommendations made by the physician to the exposed person.
  • Despite the relatively low risk of infection from an exposure, the event is associated with stress and anxiety for the exposed person.
  • Seek advice from a physician at a hospital, walk-in clinic, or community clinic within two hours of any BBF exposure.
  • Not all body fluids are implicated in transmission of viruses. Search the CDC guidelines to understand which body fluids are implicated in transmitting HIV and hepatitis B and C.

Steps

 Additional Information

1. Wash the exposed skin, mucous membrane, or eye.

Skin: Wash the area thoroughly with soap and water.

Mucous membranes or eye: Rinse area with water or normal saline.

Allow injury/wound site to bleed freely and then cover lightly.

Do not promote bleeding of percutaneous injuries by cutting, scratching, or squeezing or puncturing the skin. This may damage the skin and increase uptake of any pathogens.

Do not apply bleach or soak wound/injury in bleach.

2. Contact first aid for assistance and obtain proper forms. These forms are also available in emergency departments.

If unable to contact first aid, proceed to the emergency room.

3. Advise your supervisor or charge nurse of the incident. Ask them to complete the required form and return it to you. If available take the patient name & date of birth with you to the emergency department to allow for cross referencing and necessary follow up.

This step allows for follow-up by the manager, in relation to a BBF exposure.

4. A risk assessment should be completed within two hours. Go to the emergency room or urgent care centre and be assessed by a physician/NP.

Inform the department personnel that an occupational BBF exposure has occurred. You will be assessed and blood work will be drawn.

Emergency rooms or other health agencies are supplied with antiretroviral kits from the BC Centre for Excellence in HIV/AIDS.

Physicians will assess your risk of exposure and the risk of transmission from source.

5. Following treatment, return to your department and report the incident according to agency policy.

This ensures that the proper procedure is followed and the incident form is filled out to prevent or minimize further exposure.

Data source: BCCDC, 2015

Critical Thinking Exercises

  1. What is a point of care risk assessment?
  2. What resources are available to the nurse when making decisions about implementing additional precautions?
  3. A family member has come into the healthcare setting to visit his mother, who has been admitted with chicken pox. List four infection preventive measures to discuss with the family member.

5

1.5 Principles of Asepsis

Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the absence of all microorganisms within any type of invasive procedure. Sterile technique is a set of specific practices and procedures performed to make equipment and areas free from all microorganisms and to maintain that sterility (Centre for Disease Control, 2007). In the literature, surgical asepsis and sterile technique are commonly used interchangeably, but they mean different things (Kennedy, 2013). Principles of sterile technique help control and prevent infection, prevent the transmission of all microorganisms in a given area, and include all techniques that are practised to maintain sterility.

Sterile technique is most commonly practised in operating rooms, labour and delivery rooms, and special procedures or diagnostic areas. It is also used when performing a sterile procedure at the bedside, such as inserting devices into sterile areas of the body or cavities (e.g., insertion of chest tube, central venous line, or indwelling urinary catheter). In healthcare, sterile technique is always used when the integrity of the skin is accessed, impaired, or broken (e.g., burns or surgical incisions). Sterile technique may include the use of sterile equipment, sterile gowns, and gloves (Perry et al., 2014).

Sterile technique is essential to help prevent surgical site infections (SSI), an unintended and oftentimes preventable complication arising from surgery. It is simply post op infection that occurs at the surgical site (CDC, 2014). Preventing and reducing SSI are the most important reasons for using sterile technique during invasive procedures and surgeries.

Principles of Surgical Asepsis

All personnel involved in an aseptic procedure are required to follow the principles and practice set forth by the Association of periOperative Registered Nurses (AORN). These principles must be strictly applied when performing any aseptic procedures, when assisting with aseptic procedures, and when intervening when the principles of surgical asepsis are breached. It is the responsibility of all healthcare workers to speak up and protect all patients from infection.

 Table 1.4Principles of Asepsis

Safety considerations:
  • Hand hygiene is a priority before any aseptic procedure.
  • When performing a procedure, ensure the patient understands how to prevent contamination of equipment and knows to refrain from sudden movements or touching, laughing, sneezing, or talking over the sterile field.
  • Choose appropriate PPE to decrease the transmission of microorganisms from patients to healthcare workers.
  • Review hospital procedures and requirements for sterile technique prior to initiating any invasive procedure.
  • Healthcare providers who are ill should avoid invasive procedures or, if they can’t avoid them, should double mask.

Principle

 Additional Information

1. All objects used in a sterile field must be sterile. Commercially packaged sterile supplies are marked as sterile; other packaging will be identified as sterile according to agency policy.

Check packages for sterility by assessing intactness, dryness, and expiry date prior to use.

Any torn, previously opened, or wet packaging, or packaging that has been dropped on the floor, is considered non-sterile and may not be used in the sterile field.

2. A sterile object becomes non-sterile when touched by a non-sterile object. Sterile objects must only be touched by sterile equipment or sterile gloves.

Whenever the sterility of an object is questionable, consider it non-sterile.

Fluid flows in the direction of gravity. Keep the tips of forceps down during a sterile procedure to prevent fluid travelling over entire forceps and potentially contaminating the sterile field.

3. Sterile items that are below the waist level, or items held below waist level, are considered to be non-sterile. Keep all sterile equipment and sterile gloves above waist level.

Table drapes are only sterile at waist level.

4. Sterile fields must always be kept in sight to be considered sterile. Sterile fields must always be kept in sight throughout entire sterile procedure.

Never turn your back on the sterile field, as sterility cannot be guaranteed.

5. When opening sterile equipment and adding supplies to a sterile field, take care to avoid contamination. Set up sterile trays as close to the time of use as possible.

Stay organized and complete procedures as soon as possible.

Place large items on the sterile field using sterile gloves or sterile transfer forceps.

Sterile objects can become non-sterile by prolonged exposure to airborne microorganisms.

6. Sterile objects can become non-sterile by prolonged exposure to airborne microorganisms. Set up sterile field as close to the time of use as possible.
7. Any puncture, moisture, or tear that passes through a sterile barrier must be considered contaminated. Keep sterile surface dry and replace if wet or torn.
8. Once a sterile field is set up, the border of one inch at the edge of the sterile drape is considered non-sterile. Place all objects inside the sterile field and away from the one-inch border.
9. If there is any doubt about the sterility of an object, it is considered non-sterile. Known sterility must be maintained throughout any procedure.
10. Fluid flows in the direction of gravity. When cleaning a wound, clean the highest point first.
11. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or items contact only non-sterile areas.

** Skin cannot be sterilized. **

The front of the sterile gown is sterile between the shoulders and the waist, and from the sleeves to two inches below the elbow.

Non-sterile items should not cross over the sterile field. For example, a non-sterile person should not reach over a sterile field.

When opening sterile equipment, follow best practice for adding supplies to a sterile field to avoid contamination.

Do not place non-sterile items in the sterile field.

12. Movement around and in the sterile field must not compromise or contaminate the sterile field. Do not sneeze, cough, laugh, or talk over the sterile field.

Maintain a safe space or margin of safety between sterile and non-sterile objects and areas.

Refrain from reaching over the sterile field.

Keep operating room (OR) traffic to a minimum, and keep doors closed.

Keep hair tied back.

When pouring sterile solutions, only the lip and inner cap of the pouring container is considered sterile. The pouring container must not touch any part of the sterile field. Avoid splashes.

Data sources: Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014
Watch the video Principles of Asepsis developed by Renée Anderson & Wendy McKenzie, Thompson Rivers University School of Nursing (2014).

Critical Thinking Exercises

  1. When should a sterile field be opened (under normal circumstances)?
  2. What part of the sterile field is considered non-sterile?

6

1.6 The Operating Room Environment

The operating room (OR) is a sterile, organized environment. As a healthcare provider, you may be required to enter the OR during a surgical procedure or to set up before a surgical procedure. It is important to understand how to enter an OR area and how the OR area functions to maintain an sterile environment.

Members of the surgical team work hard to coordinate their efforts to ensure the safety and care of their patients. The surgical team is in charge of the OR and makes decisions regarding patient care procedures. The OR environment has sterile and non-sterile areas, as well as sterile and non-sterile personnel. It is important to know who is sterile and who not, and which areas in the OR are sterile or non-sterile.

Sterile OR Personnel

Non-Sterile OR Personnel

There are specific requirements for all healthcare professionals entering the OR to minimize the spread of microorganisms and maintain sterility of the OR environment. Prior to entering the OR, show your hospital-issued ID and inform the person in charge of the purpose of your visit. Refer to Checklist 9 for the specific steps to take before entering an OR.

Checklist 9: Entering the OR

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Steps

 Additional Information

1. Bring all required supplies to the OR. Sterilize or disinfect them as required. This step prevents the need to unnecessarily leave the restricted area.

Movement in the OR should be kept to a minimum to avoid contamination of sterile items or persons.

2. State the purpose of your visit to OR personnel and show your ID. This step allows for clear communication with the healthcare team.
3. Artificial nails should not be worn, and nail polish should be fresh (not more than four days old) and not chipped. Artificial nails, extenders, and chipped nail polish harbour more microorganisms than hands and can potentially contaminate the sterile area.
4. Remove all jewellery. Wedding bands may be permitted under agency policy. Jewellery harbours additional microorganisms and must be removed prior to a surgical hand scrub.
5. Don surgical attire (top and bottom). Surgical attire must be worn only in the surgical area. Tuck top into pants. Surgical attire must be worn only in the surgical area to avoid contamination outside the surgical area.
6. Cover shoes according to agency policy. Shoe covers will protect work shoes from accidental blood or body fluid spills in the OR. Shoe covers must not be worn outside the OR area.
7. Perform a surgical hand scrub according to agency policy. Surgical hand scrubs reduce the bacterial count on hands prior to applying sterile gloves. Hands are kept above waist at all times.
8. Prior to entering the restricted or semi-restricted area:
  1. Apply mask.
  2. Apply head covering to cover earrings, beard, and sideburns.
  3. Once in the OR, introduce yourself to the surgical staff and inquire about the sterile area and non-sterile areas.
Mask must cover nose, mouth, and chin for a proper seal. Mask should be changed if it becomes wet or soiled.

A surgical mask or N95 mask may be required, depending on whether the patient is on additional precautions.

Knowing what areas are sterile or non-sterile will prevent accidental contamination of sterile fields and delays in surgery.

Sterile Persons/Area

The sterile field should be created as close as possible to the time of use. Covering sterile fields is not recommended.

Sterile areas should be continuously kept in view. An unguarded sterile field is considered contaminated.

Sterile persons should keep well within the sterile area. Sterile persons should pass each other back to back or front to front. A sterile person should face a sterile area to pass it and stay within the sterile field.

Non-Sterile Persons/Area

A non-sterile person should stay at least one foot away from the sterile field, and face the sterile field when passing it.

A non-sterile person should not walk between two sterile fields or reach over the sterile field.

Data sources: Bartlett et al., 2002; Kennedy, 2013; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014

Critical Thinking Exercises

  1. Why should the sterile field always be kept in sight by the scrub nurse or circulating nurse?
  2. Name three healthcare providers who are considered sterile in the OR area.

7

1.7 Surgical Hand Scrub, Applying Sterile Gloves and Preparing a Sterile Field

Sterile procedures are required before and during specific patient care activities to maintain an area free from microorganisms and to prevent infection. Performing a surgical hand scrub, applying sterile gloves, and preparing a sterile field are ways to prevent and minimize infection during surgeries or invasive procedures.

Surgical Hand Scrub

Skin is a major source of microorganisms and a major source of contamination in the OR setting (CDC, 2010). Since skin cannot be sterilized, members of the surgical team must wear sterile gloves. The purpose of the surgical hand scrub is to significantly reduce the number of skin bacteria found on the hands and arms of the OR staff (Kennedy, 2013). A surgical hand scrub is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire (Perry et al., 2014) and lasts two to five minutes, depending on the product used and hospital policy. Studies have shown that skin bacteria rapidly multiply under surgical gloves if hands are not washed with an antimicrobial soap, whereas a surgical hand scrub will inhibit growth of bacteria under gloved hands (Kennedy, 2013).

Types of Surgical Hand Scrubs

Surgical hand scrub techniques and supplies to clean hands will vary among healthcare agencies. Most protocols require a microbial soap-and-water, three- to five-minute hand scrub procedure. Some agencies may use an approved waterless hand scrub product. See Checklist 10 for the steps to follow when scrubbing with medicated soap.

Checklist 10: Surgical Hand Scrub with Medicated Soap

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
  • All personnel entering the operating room (OR) for a specific sterile procedure must perform a surgical hand scrub.
  • Hands must be free from rings, watches, and bracelets. Nails should be free from any nail enhancements, artificial extenders, acrylics, wraps, and tips. Nail polish must be free from chips or cracks. Research shows that the amount of bacteria is nine times higher on rings and on the skin beneath the fingernails.
  • All skin on the forearm and hands (including cuticles) should be free from open lesions and breaks in skin integrity. Any allergies to the cleansing products should be reported to the manager.
  • If hands touch anything during cleaning, the entire procedure must be started from the beginning.

 Steps

 Additional Information

1. Remove all jewellery. Jewellery harbours microorganisms.
Remove Jewelry
Remove jewellery
2. No artificial nails, extenders, or chipped nail polish should be worn in the OR. Artificial nails, extenders, and chipped nail polish can harbour microorganisms.
3. Inspect hands for sores or abrasions; cover or report to supervisor as required. Open sores can harbour microorganisms.
4. Ensure sleeves are at least two to three inches above the elbows. This step prevents sleeves from becoming moist.
5. Clean hands with ABHR, or soap and water to remove visible debris. Hand hygiene is recommended by the Association of periOperative Registered Nurses (AORN).
Hand hygiene with ABHR
Hand hygiene with ABHR
6. Turn on water. Regulate the temperature of the water. Warm water is recommended to prevent drying out of hands.
Wet hands
Wet hands
7. Apply the required amount of microbial soap to hands. A good amount of soap is required to create lather for a three- to five-minute scrub.
8. Keeping hands above elbows, start timing; scrub each side of each finger, between fingers, under each nail with a nail file, and the back and front of hands for the recommended time, according to agency policy. Nail files work more effectively than a nail brush. Clean the subungal area (under the fingernails) with a nail file. Nail brushes are not recommended as they may damage the skin around the nail.
9. Scrub the arms, using an up-and-down motion, keeping hands above the elbows at all times. Wash each side of the arm from wrist to elbow for one minute. Keeping hands above the wrist allows for the microorganisms to slide off the hands into the sink.
10. Repeat the entire process with the other hand and forearm. Use an equal amount of time to wash each hand.
11. With hands raised, rinse hands and arms by passing them through running water, letting the water drip down from the fingertips to the elbow. This step allows for all the soap to be rinsed off from cleanest to dirtiest area.
12. Proceed into the operating room (keep hands above the waist), and dry arms using a sterile towel, starting at the fingertips and working down toward the forearms using a dabbing motion. This step prevents contamination of the hands and adheres to the principles of sterile technique.
Data sources:  Bartlett, Pollard, Bowker, & Bannister, 2002; Kennedy, 2013; WHO, 2009a

Applying Sterile Gloves

Sterile gloves are gloves that are free from all microorganisms. They are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected (PIDAC, 2012). Sterile gloves help prevent surgical site infections and reduce the risk of exposure to blood and body fluid pathogens for the healthcare worker. Studies have shown that 18% to 35% of all sterile gloves have tiny holes after surgery, and up to 80% of the tiny puncture sites go unnoticed by the surgeon (Kennedy, 2013). Double gloving is known to reduce the risk of exposure and has become common practice, but does not reduce the risk of cross-contamination after surgery (Kennedy, 2013).

To apply sterile gloves, follow the steps in Checklist 11.

Checklist 11: Donning & Doffing Sterile Gloves

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Choose the right size of gloves. Gloves come in multiple sizes. Make sure the gloves are tight enough so that objects are easy to pick up.
  • Sterile gloving does not replace hand washing. Hands must be washed before and after any procedure.
  • Gather all supplies and prepare your patient for the procedure prior to applying gloves.
  • Ensure the patient does not have a latex allergy prior to applying sterile gloves.
  • Sanitize the surface you are working on with antiseptic wipes (or as per agency guidelines).
  • Rings, jewelry, artificial nails, long nails, chipped polish all harbor microorganisms and increase risk to the patient.

 Steps

 Additional Information

1. Remove all jewelry. Jewelry harbors more microorganisms than do hands.
Remove Jewelry
Remove jewelry
2. No artificial nails, extenders, or chipped nail polish should be worn. Artificial nails, extenders, and chipped nail polish can harbor additional microorganisms.
3. Inspect hands for sores and abrasions. Cover or report to supervisor as required. Open sores can harbor microorganisms.
4. Ensure sleeves are at least two to three inches above the elbows. This step prevents sleeves from becoming moist, and prevents the transfer of microorganisms from the sleeves.
5. Clean hands with ABHR, or soap and water. This step decreases the bacterial count on hands and prevents contamination of sterile equipment.
Hand hygiene with ABHR
Hand hygiene with ABHR
6. Clean surface to open sterile field and raise its height to waist level. All sterile items must be kept above waist level.
7. Inspect packaging for sterility. All sterile items must be checked for sterility prior to use. Always examine sterile glove packaging for expiry date, intactness, and tears. The package should be dry. Sterile gloves have outer packaging that must be removed prior to starting the procedure of applying sterile gloves.
image
Inspect outer packaging
8. Open sterile packaging by peeling open the top seam and pulling down. Open sterile packaging.
open sterile glove packaging
Open sterile glove packaging
9. Place inner package on clean working surface and open up to see right and left gloves. Start with dominant hand first. Open packaging. This step prepares sterile surface to perform sterile application of gloves.
Place inner packaging on clean surface
Place inner packaging on clean surface
Open packaging
Start with dominant hand
Open packaging
Open packaging
10. Pick up glove for dominant hand by touching the inside cuff of the glove. Do not touch the outside of the glove. Pull glove completely over dominant hand.  This step allows ease of application.
Book pictures 2015 219
Grasp the glove of the dominant hand
Insert hand into opening
Insert hand into opening
Pull glove on up to wrist
Pull glove on up to wrist
11. Insert gloved hand into the cuff of the remaining glove. Pull remaining glove on non-dominant hand and insert fingers. Adjust gloves if necessary. This ensures proper fit of gloves.
Book pictures 2015 225
Place gloved hand under the cuff
Book pictures 2015 226
Insert fingers
Pull glove up to wrist
Pull glove up to wrist
12. Once gloves are on, interlock gloved hands and keep at least six inches away from clothing, keeping hands above waist level and below the shoulders. This step prevents the accidental touching of non-sterile objects or the front of the gown.
Keep hands above waist level and away from clothing
Keep hands above waist level and away from clothing
13. DOFFING sterile gloves.

To remove gloves, grasp the outside of the cuff or palm of glove and gently pull the glove off, turning it inside out and placing it into gloved hand.

Doing this, prevents the contamination of the hand when removing glove.
Grasp the outside of the glove 1/2 inch below the cuff
Grasp the outside of the glove 1/2 inch below the cuff
Book pictures 2015 235
Turn glove inside out
Book pictures 2015 236
Place inside-out glove in gloved hand
14. Take ungloved hand, place fingers inside the other glove, and pull glove off inside out. This step prevents the contamination of gloved hand touching ungloved hand.
Insert finger under the cuff
Insert finger under the cuff
Book pictures 2015 239
Remove second glove inside out
15. Perform hand hygiene. This removes powder from the gloves, which can irritate the skin; it also prevents contamination from potential pinholes in the gloves.
Hand hygiene with ABHR
Hand hygiene with ABHR
Data sources: Berman & Snyder, 2016; Kennedy, 2013; Perry et al., 2014; Rothrock, 2014
Watch the video Applying Sterile Gloves  by Renée Anderson & Wendy McKenzie Thompson Rivers University

Preparing a Sterile Field

Aseptic procedures require a sterile area in which to work with sterile objects. A sterile field is a sterile surface on which to place sterile equipment that is considered free from microorganisms (Perry et al., 2014). A sterile field is required for all invasive procedures to prevent the transfer of microorganisms and reduce the potential for surgical site infections. Sterile fields can be created in the OR using drapes, or at the bedside using a prepackaged set of supplies for a sterile procedure or wound care. Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile field. Sterile items can be linen wrapped or paper wrapped, depending on whether they are single- or multi-use. Always check hospital policy and doctor orders if a sterile field is required for a procedure. See Checklist 12 for the steps for preparing a sterile field.

Checklist 12: Preparing a Sterile Field

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Check physician orders and hospital policy regarding procedure.
  • Instruct patient how to assist throughout the procedure (e.g., lying still, not talking over the sterile field, or not touching sterile objects).
  • If required, check dressing on wound to assess for required supplies needed for the procedure.
  • Offer analgesic and/or bathroom to ensure patient comfort throughout the procedure.
  • Explain procedure to the patient and give an approximate time frame for completing the procedure.
  • Clean the surface you are working on with antiseptic solution.

Steps

 Additional Information

1. Perform hand hygiene, gather supplies, check equipment for sterility, and gather additional supplies (gauze, sterile cleaning solution, sterile gloves, etc.). Gathering additional supplies at the same time will help avoid leaving the sterile field unattended. Prepackaged sterile kits may not have all the supplies required for each procedure.
Hand hygiene with ABHR
Hand hygiene with ABHR
2. Place package on clean, dry, waist-level table. A clean, dry surface is required to set up a sterile field.

Items below waist level are considered contaminated.

Prepare sterile field as close to the time of procedure as possible.

Waist high, dry clean surface
Place package on waist-high, dry, clean surface
3. Remove the outside sterile packaging and discard. This allows more space to set up a sterile field.
4. Grab the outer surface’s outermost tip (corner of folded drape) and open the flap away from you. The one-inch border on the sterile field is considered non-sterile. Make sure your arm is not over the sterile field.

The inside of the sterile packaging is your sterile drape.

Stand away from your sterile field when opening sterile packaging.

Opening first flap
Open first flap
5. Grab the side flaps and open outwards, and let it lie flat on the table. Touch only the one-inch border on the sterile field. Do not reach over the sterile field.
Second flap
Second flap
Third flap
Third flap
6. Grasping the outermost corner, pull the last flap toward you and lay it flat on the table. This step creates an open sterile field.
Remove forceps prior to opening last flap
Remove forceps prior to opening last flap
Open last flap towards you
Open last flap towards you using your hand
7. Using sterile forceps, rearrange sterile equipment on the sterile field in order of usage. This step saves time for completing sterile procedure; it also limits the amount of time the sterile field is exposed to air.
Book pictures 2015 713
Arrange sterile items on field
Sterile field
Sterile field

Adding Sterile Items to a Sterile Field

8. Supplies can be opened (following packaging directions), then gently dropped onto the sterile field.

 

Gently drop items onto the sterile field or use sterile forceps to place sterile items onto the field.

If using equipment wrapped in linen, ensure sterility by checking the tape for date and to view chemical indicator (stripes on the tape ensure sterility has been achieved).

When using paper-wrapped items, they should be dry and free from tears. Confirm expiry date.

Do not flip or toss objects onto the sterile field.

Adding sterile items to sterile field
Add sterile items to sterile field
Adding sterile supplies
Add sterile supplies
9. Add solution to the sterile tray by pouring the solution carefully into the receptacle:
  • Verify solution and expiry date.
  • Open cap and place face-up on non-sterile surface.
  • Hold bottle two inches above receptacle and pour the required amount slowly and without splashing.
  • If bottle is multi-use, recap and label it with the date and time of opening. Most sterile solutions are good for 24 hours.
Do not touch the edge of the solution receptacle. Place the receptacle near the edge of the sterile field.
Sterile solution
Sterile solution
Adding sterile solution to the sterile field
Add sterile solution to the sterile field

This ensures the sterility of the solution and the use of the correct solution.

It also ensures the bottle of solution does not come in contact with the sterile field.

Lastly, it verifies the type of solution required for the procedure.

Be careful not to drip solution onto the sterile field, causing contamination. (When liquid permeates a sterile field it is called strike through.)

Data sources:  Berman & Snyder, 2016; Kennedy, 2013; Perry et al., 2014; Rothrock, 2014
Read Surgical Aseptic Technique and Sterile Field by Alberta Health Services (2013) for information about surgical asepsis and setting up a sterile field at the bedside.
For information on setting up a sterile field, watch the Simple Sterile Dressing Change video developed by TRU School of Nursing (2014).

Critical Thinking Exercises

  1. When preparing a sterile field, is the first flap opened toward or away from the healthcare provider?
  2. Name two reasons for performing hand hygiene before and after applying sterile gloves.

8

1.8 Summary

Infection control and prevention practices are a critical component of patient safety in the healthcare environment. In order to protect the public and cut healthcare costs, all healthcare professionals must take part in preventing infections before they occur. The use of routine practices, effective hand hygiene techniques, additional precautions, and sterile procedures contribute to enhancing patient safety and eliminating significant healthcare risks such as healthcare-associated infections. If effectively applied, infection control and prevention practices will prevent and minimize transmission of infections in healthcare settings.

Key Takeaways

  • Hand hygiene is the single most important part of infection prevention and control practices in the healthcare setting.
  • Plan your care: Each healthcare worker is responsible to perform a risk assessment before every contact with a patient and/or patient’s environment to ensure the proper control measures are in place to prevent transmission of infections.
  • The most common sites for HAIs are the urinary tract and the respiratory tract. It is vital to implement preventive measures at all times during patient care or during procedures related to these areas.
  • Be aware of potential risk factors of patients that make them more susceptible to infections. Susceptible patients include very young children; patients who are elderly, nutritionally deficient, or chronically ill; patients undergoing medical treatments such as chemotherapy or taking medications such as high doses of steroids; and individuals who are already ill or have open wounds (Perry et al., 2014).
  • Be aware how the chain of infection works and implement ways to break the chain of infection in practice.
  • Practice strict adherence to the principles of asepsis to prevent and minimize infections during sterile and invasive procedures.

Suggested Online Resources

  1. BC Centre for Disease Control: Blood and body fluid exposure management. This resource outlines risk assessment and guidelines for potential exposures of percutaneous, permucosal, and non-intact skin to HIV, hepatitis B, and hepatitis C.
  2. British Columbia: Home and community care – Policy manual. This manual offers guidelines for working in the community and residential care.
  3. Centers for Disease Control and Prevention: Antibiotic/antimicrobial resistance. This resource covers common viruses/bacteria found in the healthcare setting, such as:
    • Clostridium difficile infection (CDI)
    • Carbapenemase-producing organisms (CPO)
    • Multi-drug-resistant organisms (MDRO) or antibiotic-resistant organisms (ARO): MRSA/VRE
    • Severe acute respiratory syndrome (SARS)
    • Middle East respiratory syndrome (MERS)
    • Ebola virus disease (EVD)
  4. Centers for Disease Control and Prevention: Guidelines for disinfection and sterilization in healthcare facilities. The goal of this document is to reduce the rates of healthcare associated infections. Each recommendation listed is categorized according to scientific evidence, theoretical rationale, and applicability.
  5. Infection and Prevention Control Canada. (IPAC): Evidence-based guidelines. This website offers the latest reports, guidelines, standards, and policies related to infection control issues. US and international resources are also provided. These documents may be used to support your own documentation practice and best practices.
  6. Ontario Agency for Health Protection and Promotion: Routine practices and additional precautions. This excellent resource provides routine practice and additional precautions in all healthcare settings. These were developed by the Ontario Provincial Infectious Disease Advisory Committee (PIDAC) on Infection Prevention and Control (IPC).
  7. Provincial Infection Control Network of British Columbia (PICNet): BC infection control and hand hygiene module. This course teaches the basic principles of infection control in the healthcare system, sharps management, hand hygiene, blood and body fluid exposure and cleanup, the proper use of personal protective equipment, and isolation precautions.
  8. Provincial Infection Control Network of British Columbia (PICNet): Infection control guidelines.Providing health care to the client living in the community.
    This document is intended to provide guidance in the writing of policies pertaining to infection prevention and control within community health care, and home care programs and settings.
  9. World Health Organization: Clean care is safer care. This website provides links to the five moments in hand hygiene, diagrams on hand washing and hand rubs, and leaflets for teaching.

References

Accreditation Canada. (2013). Infection prevention and control. Mentum Quarterly, 5(4). Retrieved from http://www.accreditation.ca/sites/default/files/qq-spring-2013.pdf.

American Academy of Allergy, Asthma and Immunology. (2015). Latex allergies: Tips to remember. Retrieved from http://www.aaaai.org/conditions-and-treatments/Library/At-a-Glance/Latex-Allergy.aspx.

Barratt, R. L., Shaban, R., & Moyle, W. (2011). Patient experience from source isolation: Lessons from clinical practice. Contemporary Nurse, 39(2), 180-193. doi: 10.5172/conu.2011.180.

Bartlett, G. E., Pollard, T. C., Bowker, K. E., & Bannister, G. C. (2002). Effect of jewellery on surface bacterial counts of operating theatres. The Journal of Hospital Infection, 52(1), 68-70.

BC Centre for Disease Control (BCCDC). (2014). Hand hygiene. Retrieved from http://www.bccdc.ca/prevention/HandHygiene/default.htm.

BC Centre for Disease Control (BCCDC). (2015). Communicable disease control. Blood and body fluid exposure management. Retrieved from
http://www.bccdc.ca/NR/rdonlyres/E6AF842F-A899-477F-BC90-5BFF6A4280F6/0/CPS_CDManual_BBFExpMangt_20150715.pdf.

Berman, A., & Snyder S. J. (2016). Skills in clinical nursing (8th ed.). Upper Saddle River, NJ: Pearson.

Bissett, L. (2007). Skin care: An essential component of hand hygiene and infection control. British Journal of Nursing, 16(16), 976-981.

Braswell, M. L., & Spruce, L. (2012). Implementing AORN recommended practices for surgical attire. AORN Journal, 95(1), 122-140. doi: 10.1016/j.aorn.2011.10.017.

Centers for Disease Control and Prevention (CDC). (2007). Part III: Precautions to prevent the transmission of infectious agents. Retrieved from http://www.cdc.gov/hicpac/2007IP/2007ip_part3.html.

Centers for Disease Control (CDC). (2012). Frequently asked questions about Clostridium difficile for healthcare providers. Retrieved from http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html.

Centers for Disease Control (CDC). (2014). Types of healthcare-associated infections. Retrieved from http://www.cdc.gov/HAI/infectionTypes.html.

Infection Control Today. (2000). Asepsis and aseptic practices in the operating room. Retrieved from http://www.infectioncontroltoday.com/articles/2000/07/asepsis-and-aseptic-practices-in-the-operating-ro.aspx.

Kampf, G., & Loffler, H. (2003). Dermatological aspects of a successful introduction and continuation of alcohol based hand rubs for hygienic hand disinfection. The Journal of Hospital Infection, 55(1), 1-7.

Kennedy, L. (2013). Implementing AORN recommended practices for sterile technique. AORN Journal, 98(1), 14-26.

Longtin, Y., Sax, H., Allegranzi, B., Schneider, F., & Pittet, D. (2011). Hand hygiene. New England Journal of Medicine, 34(13) 24-28. Retrieved from http://www.nejm.org/doi/pdf/10.1056/NEJMvcm0903599.

Operating Room Nurses Association of Canada (ORNAC). (2011). Standards, guidelines and position statements for perioperative registered nursing practice. Retrieved from http://flex5114.weebly.com/uploads/1/4/5/1/14518934/ornac_standards.pdf.

Patrick, M., & Van Wicklin, S. A. (2012). Implementing AORN recommended practices for hand hygiene. AORN Journal, 9(4), 492-507. doi: 10.1016/j.aorn.2012.01.019.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques (8th ed.). St. Louis, MO: Elsevier-Mosby.

Provincial Infectious Diseases Advisory Committee (PIDAC). (2012). Routine practices and additional precautions in all health care settings (3rd ed.). Retrieved from http://www.publichealthontario.ca/en/eRepository/RPAP_All_HealthCare_Settings_Eng2012.pdf.

Poutanen, S. M., Vearncombe, M., McGeer, A. J., Gardam, M., Large, G., & Simor, A. E. (2005). Nonsocomial acquisition of methicillin-resistant Staphylococcus aureus during an outbreak of severe acute respiratory syndrome. Infection Control Hospital Epidemiology, 26(2) 134-137.

Public Health Agency of Canada (PHAC). (2012a). Hand hygiene practices in healthcare settings. Retrieved from http://publications.gc.ca/site/eng/430135/publication.html.

Public Health Agency of Canada (PHAC). (2012b). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Retrieved from http://www.phac-aspc.gc.ca/nois-sinp/guide/ summary-sommaire/tihs-tims-eng.php.

Public Health Agency of Canada (PHAC). (2013). The Chief Public Health Officer’s report on the state of public health in Canada: Infectious disease, the never ending threat. Retrieved from http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/infections-eng.php#a8.

Rees, J. (2017). Putting on sterile gloves. Retrieved from https://media.ed.ac.uk/media/Putting+on+sterile+gloves+VIMEO+%282017+remake%29/1_wjlyrirj.

Rothrock, J. C. (2014). Care of the patient in surgery. St. Louis, MO: Mosby Elsevier.

Siegel, J. D., Rhinehart, E., Jackson, M., & The Healthcare Infection Control Practices Advisory Committee (HICPAC). (2007). Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from Centers for Disease Control website: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.

Vancouver Coastal Health. (2017). Point of care risk assessment (PCRA). Infection prevention & control. Retrieved from http://ipac.vch.ca/Documents/Routine%20Practices/PCRA%20Algorithm.pdf.

World Health Organization (WHO). (2009a). WHO guidelines for hand hygiene in health care: First global patient safety challenge. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf?ua=1.

World Health Organization (WHO). (2009b). Five moments for hand hygiene. Retrieved from http://www.who.int/gpsc/tools/Five_moments/en/.

II

Chapter 2. Patient Assessment

9

2.1 Introduction

Assessment is an essential part of the nurse’s role and is the first step in the nursing process (Potter et al., 2019). Care provided is based on the assessment findings that the nurse has collected and thought critically about. Nurses work collaboratively with clients and the healthcare team to create care plans that help optimize client health and help the client achieve their health goals.

Depending on the context, nursing assessment can take many forms. Nurses working in communities may perform community assessments; nurses working with particular populations may perform population related assessment; and nurses working in acute care may perform specific patient assessment. When an assessment is performed, the nurse should do so in a methodical fashion ensuring thoroughness.

This chapter will cover different approaches for nurses to physical health assessment, including health history, vitals, physical assessment with details about focused assessments pertinent to each system, as well as pain assessment and how to do a quick priority assessment. Sample nursing diagnoses are provided to help the learner begin to make connections between assessment and nursing diagnoses.

The skills of physical assessment are powerful tools for detecting both subtle and obvious changes in a patient’s health. Along with this, the ability to think critically and interpret patient behaviours and physiologic changes are essential. The assessment skills outlined in this chapter are meant to provide a framework to develop assessment competencies applicable and salient to everyday practice as recommended by Anderson, Nix, Norman, and McPike (2014).

The content in this chapter is considered basic level for adult assessment. Learners are encouraged to seek other, in-depth resources about assessment to further develop their knowledge and skill.

Learning Outcomes

  • Describe four different types of assessment and when they should be used to inform care.
  • Describe the purpose of physical assessment.
  • Discuss techniques to promote a patient’s physical and psychological comfort during an examination.
  • Identify data to collect from the nursing history before an examination.
  • Incorporate health promotion and health teaching into an assessment.
  • Use physical assessment techniques and skills during routine nursing care.
  • Document assessment findings according to agency policy.
  • Begin to identify nursing diagnoses following assessment of clients.

10

2.2 Health History

The purpose of obtaining a health history is to gather data from the patient and/or the patient’s family, so the healthcare team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions. The health history is typically done on admission to hospital or a care agency, or with initial contact with community nursing services, but a health history may be taken whenever additional information may be helpful to inform care (Wilson & Giddens, 2013).

Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include symptoms described by the patient that are not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history. Checklist 13 provides a guide for obtaining subjective data during a health history.

It should be noted that the theoretical underpinnings of the different components of a health history are beyond the scope of this textbook. However, the nurse should remember that using open-ended questions allows the patient to direct the interview and may reveal information otherwise missed through closed-ended questioning.

Objective data is information that the healthcare professional gathers during a physical examination and consists of information that can be seen, felt, smelled, and/or heard by the healthcare professional. When taking a health history, data obtained through diagnostic means (i.e., vital signs, blood work, chest x-ray, etc.) may be used by healthcare professionals to understand the client’s health status.

Critical thinking is necessary to interpret and evaluate the assessment findings, and to use this to inform nursing judgement. The data gathered in a health history provides the healthcare professional an opportunity to assess health promotion practices and offer patient education (Stephen, Skillen, Day, Jensen, 2012).

It should be noted that although agency forms may differ slightly, all health histories should include main components similar to the ones listed in Checklist 13.

Checklist 13: Health History Checklist

Disclaimer: Always review and follow your agency policy regarding this specific skill.

Steps

Additional Information

Biographical data
  • Source of information
  • Name, age, gender
  • Living situation
Chief complaint; history of present illness; reason for seeking health care
  • Chief complaint
  • Onset and duration of present health concern
  • What caused the health concern to occur?
  • Signs, symptoms, and related problems
  • Alleviating and aggravating factors
  • How the concern affects life and activities of daily living?
  • Previous history and episodes of this condition
Past health history
  • Allergies (including reaction)
  • Immunization history (if applicable)
  • Chronic disease(s)
  • Acute diseases requiring treatment
  • Previous hospitalizations
  • Previous surgical interventions
  • Mental health history
  • Current medications: prescriptions, over-the-counter, herbal remedies
  • Alcohol consumption and recreational drug use
  • History of antibiotic resistant organisms (ARO)
Social data
  • Reported quality of family or friend relationships
  • Cultural health-related beliefs and practices
  • Nutrition considerations related to culture
  • Social and community considerations: interpersonal relationships and resources; caregiver responsibilities
  • Religious or spiritual beliefs and practices
  • Language and ability to communicate
  • Pertinent health history of family members (heart disease, lung disease, cancer, hypertension, diabetes, tuberculosis, arthritis, neurological disease, obesity, mental illness, substance use and abuse, genetic disorders)
Lifestyle Personal habits including:
  • Activity and exercise
  • Leisure and recreational activities
  • Sleep and rest
  • Nutrition and elimination
  • Occupational and environmental hazards
Developmental variables
  • Relationship status
  • Significant physical and psychosocial changes or concerns
Mental status assessment
  • Stressors experienced by the individual: their perception, how they cope, ability to communicate emotion
  • Coping and stress management
Patterns of health care
  • What healthcare resources the client has used in the past and is currently using
Data sources: Assessment Skill Checklists, 2014; Lloyd & Craig, 2007; Potter et al., 2019

Critical Thinking Exercises

  1. Why is it important to obtain a complete description of the patient’s present illness?
  2. Identify one reason why it is important for the nurse to obtain a complete description of the client’s lifestyle and exercise habits?

11

2.3 Pain Assessment

“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968, as cited in Rosdahl & Kowalski, 2007, p. 704).

Pain is a subjective experience, and self-reporting pain is the most reliable indicator of a patient’s experience (RNAO, 2013). Determining pain is an important component of a physical assessment, and pain is sometimes referred to as the “fifth vital sign.”

Example of a pain scale https://commons.wikimedia.org/wiki/File:Children%27s_pain_scale.JPG
Figure 2.1 Example of a pain scale
Figure 2.2 Wong-Baker assessment of pain in children scale

Pain assessment is an ongoing process rather than a single event. A variety of pain assessment tools and visual analogues are available to help with pain assessment (see Figures 2.1 and 2.2). When someone’s pain changes notably from previous findings, a more comprehensive and focused assessment should be performed. Sudden changes may indicate an underlying pathological process (Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014). It is important to assess pain at the beginning of a physical health assessment to determine the patient’s comfort level and potential need for pain comfort measures. Any time you think your patient is in pain, the mnemonic OPQRSTUV may help guide the questions to ask your patient. See Checklist 14 for more specificity regarding this approach.

Checklist 14: Pain Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Steps

 Additional Information

O: Onset
  • When did it begin?
  • How long does it last?
  • How often does it occur?
P: Provoking, palliation
  • What brings it on?
  • What makes it better?
  • What makes it worse?
Q: Quality
  • What does it feel like?
  • Can you describe it? (patient’s own words)
R: Region, radiating
  • Where is it?
  • Does it spread?
S: Severity
  • What is the intensity (0 to 10) right now, at best, on average, at worst?
  • Are there other accompanying symptoms?
T: Treatment
  • What treatments are you currently using?
  • How effective are they?
  • Any side effects?
  • What have you used in the past?
U: Understanding
  • What do you believe is causing this symptom?
  • How is this symptom affecting you or your family?
V: Values
  • What is your comfort goal?
Data source:  RNAO, 2013

In their “Clinical Best Practice Guidelines: Assessment and Management of Pain” (2013), the Registered Nurses Association of Ontario (RNAO) has published a variety of pain assessment tools for different populations including children, non-verbal adults, adults with cancer, and neonates. Table 2.1 is an assessment tool that can be used in adults with cognitive impairment.

Table 2.1 Pain Assessment Tools for Elders with Cognitive Impairment

Note: The screening tool is for the presence/absence of pain but NOT pain intensity.

Measure

Characteristics

Considerations

Pain Assessment in Advanced Dementia (PAINAD) Scale
  • Observational behavioural tool of five items: breathing, facial expression, body language, negative vocalizations, and consolability
  • Each item rated on a scale of 0–2 for a total score from 0 (no pain) to 10 (severe pain); score 1 or 2 indicates some pain
  • For use with people having advanced dementia
  • Feasible in clinical setting – can be completed in 1-3 min.
  • Clear and concise concepts, user-friendly
  • Tool can be used for screening and follow-up
  • Evidence of reliability and validity
  • Available online at http://dementiapathways.ie/_filecache/04a/ddd/98-painad.pdf
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
  • 60-item tool assessing four categories: facial expressions, activity/body movements, social and personality changes, and other (appetite or sleeping changes)
  • Items in each category are rated present or absent, for a total score of 60
DOLOPLUS-2 Scale
  • Observations of somatic, psychomotor, and psychosocial behaviours
  • Items scored on scale of 0–3, total score range from 0–30
  • Score of 5 or more indicates pain, maximum score 30
  • For use with people having mild or moderate cognitive impairment and with proxy rating when a person is unable to self-report
  • User friendly – takes minutes to complete
  • Validation done in non-English speaking people
  • Available online at http://www. assessmentscales.com/scales/doloplus
Data source: RNAO, 2013

Critical Thinking Exercises

  1. You are caring for a patient who has just returned from a surgical procedure. How might the assessment of acute pain differ from assessment of chronic pain?
  2. What is more important in pain assessment: the subjective or the objective data?

Attributions

Figure 2.1 Children’s pain scale by Robert Weis is used under a CC BY SA 4.0 licence.

Figure 2.2 The Wong-Baker scale for assessment of pain in children by Intermedichbo is used under a CC BY SA 4.0 licence.

12

2.4 Vital Signs

Temperature, pulse, respiration, blood pressure (BP), and oxygen saturation (SpO2), are measurements that indicate a person’s hemodynamic status. These are the five vital signs most frequently obtained by healthcare practitioners (Perry, Potter, & Ostendorf, 2018). Vital signs can reveal important information about a person’s health status including changes in a patient’s condition. As such the nurse’s responsibility is to consider patterns and trends in vital signs in anticipation of changes in health status, need for further investigation, and intervention (Perry, Potter & Ostendorf, 2018). Checklist 15 outlines the steps to take when checking vital signs.

 


Checklist 15: Vital Signs

Disclaimer: Always review and follow your agency policy regarding this specific skill.

 


Safety considerations:
  • Always compare findings with the patient’s baseline.
  • Consider growth and development in relation to vital signs. Vital signs vary depending on age.
  • Consider factors that may be influencing vital signs. The pathophysiology behind these factors is beyond the scope of this textbook.
  • Report concerns to the appropriate healthcare professional.
  • Consider infection control practices.

 

Steps

Further Information

Normal Values

1. Temperature:

Oral temperature: Place the thermometer in the mouth under the tongue and instruct patient to keep mouth closed. Leave the thermometer in place for as long as is indicated by the device manufacturer.

Axillary temperature: Usually 1ºC lower than oral temperature. Place the thermometer in patient’s armpit and lower the patient’s arm over the probe. Leave it in place for as long as is indicated by the device manufacturer.

Tympanic membrane (ear) temperature: Usually 0.3°C to 0.6°C higher than an oral temperature. The tympanic membrane shares the same vascular artery that perfuses the hypothalamus. Do not force the thermometer into the ear and do not occlude the ear canal.

Rectal temperature: Usually 1ºC higher than oral temperature. Use only when other routes are not available. On adults, insert the probe approximately 3.5 cm into rectum toward the umbilicus. Use lubricant.

Normal (oral) = 35.8ºC to 37.5ºC

 

 

2. Pulse (a.k.a. heart rate):

Figure 2.3 Assessing carotid pulse
Pulses can be found at many points on the body and all could theoretically be used to assess heart rate. When palpating pulses use moderate pressure, as too much pressure can impair blood flow and occlude the vessel. In some agencies scales are used to document the strength of the pulse from bounding (+4); strong (+3); weak (+2); thready (+1); absent (0).

If a pulse is regular, a 30 second count multiplied by two is generally acceptable. If a pulse is irregular, count for 60 seconds

Common pulses for assessment include:

Radial pulse: Use the pads of your first three fingers to gently palpate the radial pulse at the inner lateral wrist.

Apical pulse: Taken as part of a focused cardiovascular assessment and when the heart rate is irregular. Apical pulses are assessed using a stethoscope placed over the 4th–5th intercostal space of the midclavicular line on the left side on adults. For accuracy, an apical heart rate should be taken for a full minute. When giving medications that are dependent on the heart rate, count the apical pulse for a full minute. Auscultate for rate and regularity.

Note: It is suggested that beginner nurses concentrate on rate and regularity. With practice, and depending on where you work, your skill level with specific heart sounds may change and need to be more detailed.

There are many online resources to support learning about normal and abnormal cardiac sounds. Here’s one:

Carotid pulse: May be taken when radial pulse is not present or is difficult to palpate. Use the pads of your first three fingers to gently palpate on either side of the trachea.

Normal heart rate:
  • Newborn–1 month: 100–175
  • 1 month–2 years: 90–160
  • Age 2–6 years: 70–150
  • Age 7–11 years: 60–130
  • Age 12–18 years: 50–110
  • Adult and older adult: 60–100

 

3. Respiration rate:

Count respiratory rate unobtrusively by observing the rise and fall of the patient’s chest or abdomen. Consider doing this while you are taking the pulse rate, so the patient is not aware that you are taking the respiration rate.

If the respiratory rhythm is regular, count for 30 seconds and multiply times two to determine respiratory rate / minute. If the respiratory rhythm is irregular or less than 12 / minute, count for a full minute.

Normal respiratory rate per minute:
  • Newborn–1 month: 30–65
  • 1 month–1 year: 26–60
  • 1–10 years: 14–50
  • 11–19 years: 12–22
  • Adult & older adult: 10–20

 

4. Non-invasive blood pressure (NIBP):
DSC_2215
Blood pressure cuff

Invasive BP readings involve direct readings from an artery and would occur in a critical care area.

The average blood pressure (BP) for a healthy adult is 120/80 mmHg, but variations are normal for various reasons. The systolic pressure is the maximum pressure on the arteries during left ventricular contraction. The diastolic pressure is the resting pressure on the arteries between each cardiac contraction.

Choosing the correct BP cuff size: The length of the cuff’s bladder should be approximately 80% of the circumference of the upper arm. The width of the cuff should be approx 2/3 of the upper arm. In other words allow for approximately two finger widths between the axilla and the top of the cuff and two finger widths between the antecubital fossa and the bottom of the cuff.

The patient may be sitting or lying down with the bare arm at heart level.

Two step method auscultation method: The two step method will allow you to approximate the BP prior to the reading, thus helping to prevent false low readings.

Apply the BP cuff to the upper arm by ensuring correct size and lining the arrows up to the brachial artery. On the same arm, palpate the radial or brachial artery. Close the pressure bulb. Inflate the BP cuff until the pulse rate is no longer felt. Then inflate an additional 20 to 30 mmHg. This will give you an approximate systolic pressure and help you to determine the maximum inflation point.

Open the pressure bulb and deflate the cuff and wait approximately one minute.

Place the bell of the stethoscope over the brachial artery, place the stethoscope ear pieces in your ears. Close the pressure bulb. Inflate the cuff to the approximated systolic pressure and deflate the cuff slowly and evenly (approx 2–3 mmHg / second) noting the points on the manometer at which you hear the first appearance of sound (systolic BP), and the disappearance of sound (diastolic BP). After the last sound is heard, quickly deflate the cuff.

Using an NIBP: Ensure cuff size is correct. Align the artery with the arrows on the cuff. Operate the machine as per manufacturers instructions.

Additional resource:

Deans, B. (2013, March 20). Choosing & positioning a blood pressure cuff [Video file]. Retrieved from https://www.youtube.com/watch?v=II0ioJNLnyg.

Normal blood pressure
Age Normal Systolic Range Normal Diastolic Range
Newborn to 1 month 45–80 mmHg 30–55 mmHg
One to 12 months 65–100 mmHg 35–65 mmHg
Young child (1–5 years) 80–115 mmHg 55–80 mmHg
Older child (6–13 years) 80–120 mmHg 45–80 mmHg
Adolescent (14–18 years) 90–120 mmHg 50–80 mmHg
Adult (19–40 years) 95–135 mmHg 60–80 mmHg
Adult (41–60 years) 110–145 mmHg 70–90 mmHg
Older adult (61 and older) 95–145 mmHg 70–90 mmHg

 

5. Oxygen saturation (SpO2):
DSC_2214
Pulse oximeter sensor
A pulse oximeter sensor attached to the patient’s finger or earlobe measures light absorption of hemoglobin and represents arterial SpO2.

Refer to Chapter 5.3 Pulse Oximetry for more information.

A  healthy person should have an SpOof  ≥ 97%.

 

 

Data sources: Hill & Smith, 1990; Jarvis, Browne, MacDonald-Jenkins, & Luctar-Flude, 2014; Lapum, Verkuyl, Garcia, St-Amant, & Tan, 2018; Stephen, Skillen, Day, & Jensen, 2012

Critical Thinking Exercises

  1. Identify four factors that can influence heart rate.
  2. Identify two situations that can influence blood pressure.
  3. Discuss why someone with a lung disease like COPD might have lower than normal SpO2.
  4. What is a normally accepted range for SpO2 in a client with COPD?

Attribution

Figure 2.3 Assessing carotid pulse by author is licensed under a Creative Commons Attribution 4.0 International License.

13

2.5 Head-to-Toe / Systems Approach to Assessment

In the course of their work doing direct patient care, nurses use a combination of head-to-toe and focused assessments to gather data about the patient. The assessment findings, when considered with some level of clinical judgement and critical thinking, inform the healthcare professional about the patient’s overall condition and form the basis of the plan of care (Potter et al., 2019).

Assessment includes the collection of subjective data – what the patient tells you. Assessment also includes the collection of objective data – what the nurse observes through their senses. Objective data is collected during the physical examination using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013).

Head-to-toe assessments or systems assessments include all the body systems and a systematic approach to collecting data. They provide the nurse with an overall understanding of each patient. They are done when the nurse first meets the patient (for example, when the patient is admitted to the unit and at the beginning of a shift) and when prompted by a change in patient health status.

Focused assessments, sometimes called priority assessments, are often a part of a head-to-toe assessment. They involve the search for detailed information about a specific body system(s). Knowing which system(s) to focus on depends upon the client’s presentation and the nurses’ knowledge of nursing, pathophysiology, pharmacology, and other bodies of knowledge (Potter et al., 2019; RCH, 2017).

Unusual findings must always be considered in relation to the patient’s health history. Some issues may be old and not fixable. New or emerging issues may require action (some rather urgently) to avoid harm to the patient.

The following sections are set up to provide the learner with general guide to objective and subjective data collection starting at the head and following a general systems approach to assessment for an adult. The sections include:

At the end of each section is additional information outlining details that may be included in a focused assessment should the nurse decide such detail is necessary. This is by no means an exhaustive list. The guide is primarily intended for a student and/or a beginning level nurse. Other more comprehensive texts will help the learner build knowledge around health assessment.

At the end of each section are sample nursing diagnoses to help you begin to understand how assessment findings inform nursing diagnosis.

Critical Thinking Exercises

  1. Consider why having a systematic approach to assessment might be important.
  2. Identify two situations where a focused priority assessment might be more appropriate than a full head-to-toe assessment.

 

14

2.6 Head-to-Toe Assessment: head and neck / Neurological Assessment

The neurological system is responsible for all human function. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen, Skillen, Day, & Jensen, 2012). A neurological assessment begins when the nurse first interacts with the client and involves observations about appearance, communication patterns, and general behaviour. The first part of the checklist provides a general overview of performing a basic neurological assessment. In some situations a more focused neurological assessment is necessary. The last part of the checklist provides some guidelines for some elements of a focused neurological assessment.

Checklist 16 provides a guide for subjective and objective data collection in a neurological assessment.


Checklist 16: Head and Neck / Neurological Assessment

Figure 2.4 Nervous system
Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Document according to agency guidelines.

 

Objective Data

Consider the following observations.

Steps

Additional Information

General appearance
Figure 2.5 Observe general appearance
Observations about general appearance may provide insight into other physical or psychosocial issues affecting the patient.

If appearance is unkempt, it may suggest that the patient struggles with achieving activities of daily living. The nurse would further their questioning to elicit greater understanding, and potentially to refer to other healthcare professionals subsequently. 

 

Level of consciousness (LOC)

 

Altered LOC may indicate substance use, fatigue, brain injury, neurological disorder, mania, or depression.
Inspect eyes & nose for drainage.

 

Drainage from eyes or nose may indicate infection, allergy, or injury.
Note nature of eye contact during interview.

 

The extent of eye contact may reflect cultural norms, individual way of being, or possibly mental health issues.
Glasses, contacts, hearing aids

 

People who need these devices but don’t have them, or if the devices are not in working order, may experience some level of isolation because of difficulty interacting with the world around them.
Inspect for facial asymmetry.
Figure 2.6 Observe for facial asymmetry
Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment.
Evidence of nasal trauma. Ability to breathe through nose.

 

Nasal flaring or use of accessory muscles when breathing may indicate altered breathing patterns. Unusual findings should be followed-up with a focused respiratory assessment.
Inspect mouth, tongue, and teeth for moisture, colour, dentures, hygiene.

 

Dry mucous membranes may indicated altered hydration. Dental disease can influence one’s general health.
Ability to swallow

 

Difficulty swallowing may suggest neurological impairment. Frequent coughing or choking associated with eating or drinking may suggest risk of aspiration. Unusual finding should be followed-up with a swallow assessment and a referral to an occupational therapist.
Neck range of motion (ROM)

 

This includes flexion, extension (front and back, and side to side) and ability to rotate the neck side to side.

Impaired neck ROM may indicate an old injury. Neck pain and stiffness (nuchal rigidity) may be related to old injury or signs and symptoms of a serious neurological illness.

Ability to communicate

 

Difficulty communicating may be the result of a language barrier or neurological impairment. Communication barriers related to language differences between the patient and healthcare givers might be alleviated through interpreters making information available in the patient’s language.

Communication barriers related to neurological impairment require further investigation and a creative approach during patient care.

General arm and leg strength.
Figure 2.7 Assessing hand strength
Assess dorsiflexion
Assess plantar flexion
 

General arm and hand strength can be assessed by asking the patient to extend their arms and grip the nurse’s hands simultaneously.

General leg strength can be assessed by asking the patient to dorsiflex, plantar flex, and bend each knee.

Dorsiflexion strength can be assessed by asking the patient to pull up on their feet while the nurse applies some resistance to the top of the feet.

Plantar flexion strength is assessed while the nurse applies some resistance to the bottom of the feet while asking the patient to push (i.e., step on the gas).

Always compare extremities.

Subjective Data

Ask about vision, hearing, headaches, neck stiffness, history of head injury, neurological disease, history of seizures, stroke, memory loss, mental health history.

Focused neuro assessment may also include:

Pain Assessment  See Chapter 2.42 Pain Assessment
Mental Status Exam (MSE): Is used in psychiatry to guide the examiner to collect data and form impressions about an individual’s mental health. MSE involves the following components:
  • Appearance, Motor, Speech, Thought Content, Thought Process, Perception, Intellect, Insight

For more resources about MSE, go to RNAO’s Nursing Best Practice Guidelines: Outline of a Mental Status Examination.

Mini-Mental State Exam (MMSE): Used to measure cognitive impairment and often performed in the context of persons with dementia. For more information about the MMSE see BCGuidelines.ca (2014) Standardized Mini-Mental State Exam (SMMSE)
Glasgow Coma Scale (GCS): Used to guide assessment in patients with head injury, suspected brain bleeds, stroke, and cranial surgery, and in persons with altered level of consciousness. In general, the GSC measures assess:
  • Best eye-opening response
  • Best motor response
  • Best verbal response

The lower the score, the more serious the neurological impairment. This assessment tool allows for objective assessment and greater reliability in terms of being able to observe patterns and trends in the patient’s health status.

Glasgow Coma Scale (adapted from Jarvis et al., 2014, p. 699)
Best eye-opening response

Record “C” if eyes closed due to swelling.

1 No response
2 To pain
3 To speech
4 Spontaneously
Best motor response (to painful stimuli)

Press fingernail bed, and record best upper-limb response.

1 No response
2 Extension – abnormal
3 Flexion – abnormal
4 Flexion – withdrawal
5 Localizes pain
6 Obeys verbal command
Best verbal response
  • Record “E” if endotracheal tube is in place.
  • Record “T” if tracheostomy is in place.
1 No response
2 Sounds – incomprehensible
3 Speech – inappropriate
4 Conversation – confused
5 Oriented × 3 (to person, place, and time)

For more information about neuro assessment go to Critical Care Services Ontario’s Guidelines for Basic Adult Neurological Observation.

Assess arm drift by asking the patient to extend their arms in front of them and close their eyes. Drift of one arm may suggest neurological dysfunction. Report concerns immediately.
Pupil Assessment: Assess pupils for size, equality, reaction to light, and consensual reaction to light.

In a darkened room ask the patient to look at your nose. With a lit flashlight, shine the light moving from the lateral across the open eye to the space between the eyes. Note the pupil’s reaction to light.

Repeat on the other side.

To test consensual reaction, have the patient look at your nose. Shine a flashlight from the hairline at the mid-forehead to the space between the eyes. Observe for the pupils to react equally at the same time.

Pupils that are equal and reactive to light are described as PERL.

Alterations may be a part of the patient’s norm or they may indicate severe neurological dysfunction, and should be reported immediately.

Dermatome Assessment: Dermatomes are areas of skin supplied by a single spinal nerve.

To perform a dermatome assessment use ice. Begin at the neck area. Move the ice downward along the side of the patient’s body asking them to indicate if and when sensation changes. Continue to the lateral side of the foot. Repeat on the other side.

Figure 2.8 Dermatomes
Dermatome assessment may be indicated in persons with spinal cord injury or when patients receive spinal or epidural analgesics (local anesthetics).

Depending on the context, changes in dermatome levels may indicate local anesthetic is moving up or down in the epidural space.

In spinal cord injury, alterations in dermatomes may indicate improving or worsening changes in patient status.

Document blocked dermatomes according to agency guidelines. E.g., Right side: T12-L1; Left side: L1-L4.

Sedation Score Assessment: Nursing assessment of opioid induced sedation is quick and easy. Having a guide provides some level of consistency between assessors and provides important information to the healthcare team about trends in the patient’s level of sedation. Sample Sedation Score Assessment (adapted from Pasero, 2009)
1 Awake & alert
2 Slightly drowsy, easily aroused
3 Slightly drowsy, easily aroused
4 Somnolent, minimal or no response to verbal or physical stimulation
5 / S Sleeping

Sedation scores may form a part of an agency’s assessment protocol(s). Some agencies provide direction for opioid use based on the sedation score.

The National Institute of Health Stroke Scale (NIHSS): Used specifically when stroke is suspected. It is often a part of an institution’s stroke protocol. For reference see:

Heart and Stroke Foundation. (2019). Canadian partnership for stroke recovery. Retrieved from https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf.

Potential neurological related nursing diagnoses:
  • Pain related to injury
  • Risk of falls due to altered level of consciousness
  • Risk for injury related to disturbed sensory perception
Data sources: Alberta Health Services, 2009; Assessment Skill Checklists, 2014; Critical Care Services Ontario, 2014; Heart and Stroke Foundation, 2019; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Pasero, 2009; Perry, Potter, & Ostendorf, 2018; RCH, 2015; RNAO, n.d.; Stephen et al., 2012; Wilson & Giddens, 2013
Watch the video Neurological Assessment – Basic by Renée Anderson and Wendy McKenzie, Thompson Rivers University, 2019
Watch the video Assessing Range of Motion and Strength by Candace Walker and Wendy McKenzie, Thompson Rivers University

 

Critical Thinking Exercises

  1. What patient situations would require a dermatome assessment?
  2. When caring for a client post CVA, consider the difference between completing a Glasgow Coma Scale (GCS) assessment and a National Institutes of Health Stroke Scale (NIHSS).
  3. Besides opioid induced sedation, identify one other situation where sedation score might be appropriate part of an assessment.

Attributions:

Figure 2.4 Neurological System by the Emirr  is used under a CC BY 3.0 license.

Figure 2.5 A Man’s Face by Christiaan Brigs is used under a CC BY-SA 3.0 license.

Figure 2.6 Bells Palsy by CDC and United States Department of Health and Human Services is in the public domain.

Figure 2.8 A Diagram Showing Human Dermatomes by Ralf Stephanis in the public domain.

15

2.7 Head-to-Toe Assessment: Chest / Respiratory Assessment

Checklist 17 provides a guide for subjective and objective data collection in a respiratory assessment.

Checklist 17: Chest / Respiratory Assessment

Figure 2.9 Respiratory System
Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.

 

Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Document according to agency guidelines.

 

Objective Data

The data that we can observe with our senses.

 

Steps

Additional Information

Observe the work of breathing including use of accessory muscles.
Figure 2.10 Observe for work of breathing
Increased work of breathing may be observed through a spectrum of responses including a small amount of nasal flaring through to use of all accessory muscles. Increased work of breathing is often associated with an increased respiratory rate.

The patient may appear distressed and/or feel anxious. Likewise they may not appear distressed, depending on the severity and other comorbidities. Ability to speak may be affected.

Increased work of breathing may indicate respiratory compromise and impaired oxygenation caused by things like acute airway obstruction, pulmonary edema,  atelectasis, and others.

Unusual findings should be followed up with a focused respiratory assessment.

More resources:

Expansion / Retraction of Chest Wall The chest wall should expand and contract symmetrically. If not, consider if this is a new or pre-existing condition.

Chest expansion may be asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, pneumothorax, or hemothorax.

Assess respiratory rate by inconspicuously observing breathing. One way to do this is to palpate radial pulse for a full minute but use some of that time to count respirations.

Likewise, placing your hand on the patient’s chest and counting the rise / fall cycles

Assessing respiratory rate.
Normal respiratory rate (interpreted as respirations per minute):
  • Newborn: 30–60
  • Infant (6 months): 30–50 
  • Toddler (2 years): 25–32
  • Children (3–12 years): 20–30
  • Adolescents (13–18 years): 12-20
  • Adults: 12–20

If a patient’s respiratory status is stable, it may be appropriate to count respirations for 30 seconds and multiply by two to determine respiratory rate.

Pulse Oximetry: Consists of a probe with a light-emitting diode (LED) attached to the patient’s finger, forehead, or ear. Beams of red and infrared light are emitted from the LED, and the light wavelengths are absorbed differently by the oxygenated and the deoxygenated hemoglobin (Hgb) molecules. The receiving sensor measures the amount of light absorbed by the oxygenated and deoxygenated Hgb in the arterial (pulsatile) blood. (Perry et al., 2018).
Pulse oximetry
The more Hgb that is saturated with oxygen, the higher the SpO2, which should normally measure above 95% oxygen saturation (SpO2) (Perry et al., 2018).

See Chapter 5.3 Pulse oximetry.

Use a stethoscope to auscultate breath sounds anterior and posterior for quality of air entry and any adventitious sounds. Assess bilaterally comparing one side with the other in a systematic fashion.

Diminished air entry may indicate atelectasis, pneumonia, hemothorax, pneumothorax, or collapsed lung.

The presence of crackles or wheezing must be further assessed, documented, and reported. If such things are affecting the patient negatively, intervention is needed.

Crackles may indicated mucous related to asthma or chronic obstructive pulmonary disease (COPD), or fluid related to pulmonary edema.

Wheezing may indicate bronchoconstriction related to asthma, bronchitis, or emphysema.

Friction rub (creaking) may indicate inflammation related to pleurisy.

The nurse should always consider what interventions they can implement independently and what interventions have been ordered by the authorized prescriber to relieve impaired oxygenation.

More resources:

Cough & Sputum The nurse might observe coughing and expectorated sputum.

Reasons for coughing might include bacterial or viral infection, aspiration, or presence of sputum. Observe and ask if the cough is a concern for the patient.

If sputum is present, observe or inquire about amount, colour, and consistency. Ask if sputum is normal for the patient.

Subjective Data

  • If you don’t already know, ask about respiratory diseases (COPD, asthma, cystic fibrosis). Presence of these may provide insight into explaining other respiratory assessment findings.
  • Ask about use of respiratory medications. People with chronic respiratory disease often use one or more inhaled medications.
  • Ask about breathing. Does the person experience trouble with breathing or shortness of breath?
  • Do they have a cough?
  • Is sputum present? If so what is the amount, colour, and consistency? Is this normal?
  • Do they smoke? If so, what and how much?
  • Ask about environmental exposures that may affect breathing. Some environmental allergies (airborne nut allergy, perfumes, cleaners) trigger respiratory difficulty.

Focused respiratory assessment may also include:

If a chest tube is present, ensure the tube is intact and secure and that the drainage system is functioning. Auscultate chest sounds, perform a respiratory assessment including palpating for evidence of subcutaneous emphysema at and near the chest tube insertion site. See 10.6 Chest Tube Drainage Systems
Arterial blood gasses (ordered by prescriber or as per agency protocol)
Potential respiratory related nursing diagnoses:
  • Impaired oxygenation as evidenced by increased respiratory rate and use of accessory muscles to breathe.
  • Risk of respiratory infection related to mucous production  associated with COPD.
  • Readiness to stop smoking.
Sources: Assessment Skill Checklist, 2014; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Perry, Potter, & Ostendorf, 2018; Potter et al, 2019; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. A client is experiencing mild respiratory distress. Identify two important strategies to address this.
  2. What potential respiratory issues might the nurse anticipate for the post op patient? Identify an important nursing intervention for each.
  3. Identify two strategies the nurse might implement for the immobile client whose chest sounds reveal decreased air entry to the bases.

Attributions:

Figure 2.9 An Illustration Depicting the Respiratory System by BruceBlaus is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 2.10 Chest Landmarks, for Radiography and Other Chest Imaging Techniques by P. Lynch is used under a Creative Commons Attribution 2.5 license.

16

2.8 Head-to-Toe Assessment: Cardiovascular Assessment

Checklist 18 provides a guide for subjective and objective data collection in a cardiovascular assessment.

Checklist 18: Cardiovascular (CV) Assessment

Figure 2.11 Cardiovascular system
Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.

Objective Data

Consider the following observations.

Steps

 

Additional Information

Colour of Skin & Mucous Membranes Cyanosis (a bluish tinge) may suggest inadequate oxygenation and CV compromise
Temperature of Extremities Hot skin may suggest fever and should be followed up with full vital signs, report to the primary prescriber, and investigation of any suspected sources of infection.

Cold skin may suggest existing or new circulatory related issues.

Blood Pressure, Heart Rate, SpO2 Baseline vital signs are important in any assessment. Vital signs should be compared to the patient’s normal values. Patterns and trends outside of the normal range should be reported to the appropriate person.

See Chapter 2.4 Vital Signs

Capillary Refill

Press on the nail beds of toes and/or fingers until there is blanching (whiteness). Release the pressure and count how many seconds until the patient’s full colour returns.
  • Brisk capillary refill: < (less than) 3 seconds
  • Delayed capillary refill: > (greater than) 3 seconds

Delayed cap refill may suggest cardiovascular or respiratory dysfunction and should be followed-up with a focused assessment.

Edema
Figure 2.12 Hand edema
Figure 2.13 Foot and ankle edema
Edema can be the result of many things, including:
  • Inflammatory response from things like bee stings, sprains, or injury
  • Altered venous return
  • Diseases of the lymphatics
  • Fluid shifts
  • Side effects of some medications
  • Circulatory overload
  • Heart failure

It is important to ask the patient if is this normal for them.

Observe limbs simultaneously in order to compare. Unilateral edema of the leg may suggest deep vein thrombosis (DVT).

Edematous tissue has a high risk of skin breakdown. Implement strategies to maintain skin integrity.

Palpate Extremities to Quickly Assess Colour, Warmth, Movement, and Sensation (CWMS), Capillary Refill of Hands and Feet

Colour and warmth provide information about perfusion.

Movement provides a brief overview about musculoskeletal function of extremities, which is affected by circulation.

Sensation: by asking if the client has numbness and/or tingling in extremities the nurse gets a brief overview of client baseline. Altered sensation may be the result of impaired neurological function or impaired perfusion.

Palpate pulses for symmetry in quality, rate, and rhythm. This provides information about perfusion.

Asymmetry in relation to assessment findings may indicate a number of things including cardiovascular conditions, history of injury, or post surgical complications.

Report concerns to the appropriate healthcare professional.

 

Auscultate: Apical Heart Rate for Rate and Rhythm

Apical pulses are assessed using a stethoscope placed over the 4th–5th intercostal space of the midclavicular line on the left side on adults. For accuracy, an apical heart rate should be taken for a full minute. Identify S1 and S2 and follow up on any unusual findings.

See Chapter 2.3 Vital Signs

Clubbing of Nails
Figure 2.14 Clubbing of finger nails
Clubbing of nails may suggest underlying cardio pulmonary disease

Subjective Data

Ask about chest discomfort, pain, or pressure. All of these may be indicative of a larger cardiovascular issue. Reports of these must be followed up with a more detailed assessment and notification to the appropriate healthcare provider.

A focused cardiovascular assessment may also include:

Rating of Edema Using an Objective Scale
Figure 2.15 Pitting edema
Rating of Edema
Grade Description Depth of Indent Time to Return to Normal
+1 Slight pitting, no visible change in the shape of the extremity; 0–1/4 inch
(< 6 mm)
Rapidly
+2 No marked change in the shape of the

extremity

1/4–1/2”
(6–12 mm)
10–15 seconds
+3 Noticeably deep pitting, swollen extremity 1/2–1”
(1–2.5 cm)
1–2 minutes
+4 Very swollen, distorted extremity > 1”
(>2.5 cm)
2–5 minutes
Adapted from Brodovicz et al., 2009

Jugular Vein Distension (JVD)

Figure 2.16 Jugular vein distension (JVD)
Jugular vein distension of more than 3 cm above the sternal angle while the patient is sitting at
45 degrees may indicate heart failure.
Rating of Peripheral Pulses Using an Objective Scale
Figure 2.17 Pulse Sites
Pulse quality may be important to assess following surgery when the patient is at risk for arterial compromise (i.e., graft occlusion). A deterioration in pulse quality might suggest arterial occlusion.
 Peripheral Pulse Rating Scale
Rating Description
0 No pulse
+1 Faint but detectable
+2 Slightly diminished compared to normal
+3 Normal
+4 Bounding
Adapted from Hill & Smith, 1990
Auscultation of Heart Sounds Depending on the context, nurses may need to have the skill to be able to assess specific heart sounds.

Additional resources:

Potential cardiovascular related nursing diagnoses:
  • Activity intolerance related to diminished cardiac function.
  • Acute chest pain due to increased cardiac workload.
  • Ineffective cardiac or peripheral tissue perfusion secondary to heart failure.
  • Learning need in relation to risk factors associated with cardiovascular disease.
Data sources: Assessment Skill Checklist, 2014; BCCNP, 2018; Brodovicz et al., 2009; Hill & Smith, 1990; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Perry, Potter, & Ostendorf, 2018; Potter et al., 2019; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. A client has +4 edema to bilateral feet and ankles. Identify two strategies to assist in maintaining skin integrity.
  2. A client has just had a femoral popliteal bypass. Which peripheral pulses should be included in the assessment specific to determining arterial perfusion of the affected leg?

Attributions:

Figure 2.11 3D Human Heart and Circulatory System Illustration by Bryan Brandenburg is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.12 Edema of Right Hand Due to Allergic Reaction by CNX Openstax is used under a Creative Commons Attribution 4.0 International license.

Figure 2.13 Post Heart Transplant 21 October 2018 Harefield Hospital by Ryaninuk is used under a Creative Commons Attribution 4.0 International.

Figure 2.14 Clubbing Fingers by Desherinka is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 2.15 Pitting Edema by James Heilman is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.16 JVD by Ferencga is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.17 Pulse Sites by  CFCF  is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.

17

2.9 Head-to-Toe Assessment: Abdominal / Gastrointestinal Assessment

Checklist 19 provides a guide for subjective and objective data collection in an abdominal /  gastrointestinal assessment.

Checklist 19: Abdominal / Gastrointestinal Assessment

Figure 2.18 GI system
Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.

 

Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity. 

Objective Data

Consider the following observations:

Steps

Additional information

Overall Appearance: Observe for abdominal distension, stretch marks, contour, symmetry, presence and type of ostomy, overweight or underweight.
Figure 2.20 Ileostomy bag
Figure 2.19 Abdominal distension
Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, cancer, and pancreatitis.

An abdomen that appears thin with little adipose tissue might suggest nutrition issues.

It is important for the nurse to ask “is this normal for your abdomen” to help differentiate patient “norm” to signs and symptoms that may indicate an acute issue.

Unusual findings may indicate compromised GI function.

 

Auscultate Bowel Sounds

 

Auscultate for bowel sounds
Figure 2.21 Abdominal quadrants
Divide the abdomen into quarters. Auscultate in each quadrant for evidence of gurgling, which suggests peristalsis.

Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileus.

Hypoactive or absent bowel sounds may be present after GI surgery or when peritonitis or paralytic ileus are present.

Palpate Lightly in All Four Quadrants for Distension, Firmness, Masses, Pain

Firmness may indicate excess gas, ascites, peritonitis. Always ask the patient “is this normal for you?”
Observe stool to identify important characteristics. Sometimes observing stool is an important part of the assessment process. Characteristics of bowel movements can assist with diagnosis and to help determine effectiveness of treatment for bowel related conditions.

 

Resource: Bladder and Bowel Foundation (nd).  Bristol Stool Chart.  https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC002_Bristol-Stool-Chart-Jan-2016.pdf

 

Subjective Data
  • Ask about last bowel movements and normal bowel patterns. Changes to bowel patterns may indicate a larger GI issue. Normal bowel patterns vary across individuals. Knowing what is normal will help the nurse differentiate if there is a new or emergent concern requiring attention.
  • Ask about flatus, nausea, vomiting, and pain. Any of these may be symptoms of a GI issue.
  • Ask about dietary habits. What kinds of foods does the patient normally eat? Has this changed?
  • Ask about recent weight gain or weight loss. Unexplained weight loss or weight gain may indicate a larger issue and may need investigation. In the surgical context, significant weight loss can result in delayed wound healing and risk of wound dehiscence.
Focused GI assessment may also include ostomy assessment. See Chapter 11: Ostomy Care
Potential GI related nursing diagnoses:
  • Need for information in relation to low fat foods.
  • Alteration in bowel function (constipation or diarrhea) related to ….
  • Potential for delayed wound healing due to altered nutrition status (10 kg unexplained weight loss in 1 month)
  • Alteration in dietary intake secondary to slowed GI function post op
Data sources: Assessment Skill Checklist, 2014; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Potter et al., 2019; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. A patient who experiences intermittent constipation asks what they might do to promote bowel regularity. Describe three nursing interventions that the nurse might discuss.
  2. Describe the character of stool expected from an ileostomy.

Attributions:

Figure 2.18 Gastrointestinal Tract by Mariana Ruiz, Jmarchn is in the public domain.

Figure 2.19 Big Man Big Stomach by Mike Baird is used under a CC BY 2.0 license.

Figure 2.20 Ileostomy with Bag by Remedios44 is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 2.21 Abdominopelvic Quadrants by Bruce Blaus is used under a Creative Commons Attribution 3.0 Unported license. 

18

2.10 Head-to-Toe Assessment: Genitourinary Assessment

Checklist 20 provides a guide for objective and subjective data collection in a genitourinary assessment

20:  Genitourinary Assessment

Figure 2.22 Genitourinary system
Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity. 

Objective Data

Consider the following observations.

Steps

Additional information

Observe: Look for presence of urethral catheter, ileal conduit, nephrostomy tube(s), suprapubic catheter, and condom catheter. If present, note the colour, presence, and nature of any odour, and volume of urine in the urine collection system.

Observe the urinary meatus if urethral catheter present for signs of irritation, including skin integrity and urethral ooze.

Observe the genitalia, noting any lesions to suggest possible sexually transmitted infection

Figure 2.24 Observe genitalia for lesions
Figure 2.23 Urine drainage system
Urine drainage systems suggest compromised urinary function. All urine drainage systems require care and attention to reduce risk of urinary tract infection and other issues.

Urine drainage tubes should be secured to avoid tension at the insertion site and/or accidental removal.

Unusual findings in voiding patterns or urinary output may indicate compromised urinary function. Follow up with a focused GU assessment.

Fever may suggest urinary tract infection. In the elderly, urinary tract infections can result in delirium and as a result present serious safety concerns for the patient.

The colour of urine might suggest hydration status.

Palpate the suprapubic abdomen to assess for pain, possible urinary retention Palpation while asking about pain or urgency may suggest urinary retention. Bladder scan if equipment is available.
Subjective Data
  • Ask if the patient is experiencing any difficulty with voiding.
  • Ask the patient about colour of their urine.
  • Ask about history of urinary tract infections, burning, frequency, presence of blood in urine, sediment, odour with urine, and history of kidney, renal, and genital health issues.
  • Ask about nocturia and incomplete bladder emptying. In older males, alterations to urinary habits (frequency, urgency, nocturia) may suggest prostate disease.
  • Ask the client if they have any concerns about their sexual health.

Focused GU assessment may also include:

Bladder scan to assess for residual urine volume Bladder scan according to manufacturer and agency guidelines.

Read this journal article for more information on bladder scanning: 

In and out urethral catheter insertion for residual urine volume Assist the patient to void and catheterize immediately following the attempt. Note the volume of the void and the volume associated with the catheterization.

Catheterize as directed by prescriber or as per nurse’s independent scope of practice and agency policy. See Chapter 10.4 Urinary Catheters

Presence of an ileal conduit (urostomy), nephrostomy
Figure 2.25 Nephrostomy drainage system
Note amount and character of urine.

Urine via an ileal conduit passes through a piece of bowel, the character of the urine will likely be cloudy from mucous and likely foul smelling from the bacterial that lives in the ileal conduit. See Chapter 11.2 Ostomy Care

  • Ileal conduit / urostomy: Assess the stoma.
  • Nephrostomy insertion sites: Assess the drain insertion site and condition of the dressing. The insertion site should be covered with a sterile dressing.
Potential genito urinary related nursing diagnoses:
  • Altered pattern of urinary elimination (retention).
  • Risk of urinary tract infection due to urethral foley.
Data sources: Assessment Skill Checklist, 2014; BCCNP, 2018; Davis, Chrisman, & Walden, 2012; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Perry, Potter, & Ostendorf, 2018; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. Identify two strategies to prevent urinary tract infection in the person with an indwelling urethral catheter.
  2. A patient with an ileal conduit asks why their urine is cloudy. Explain.

Attributions:

Figure 2.21 Illus. Urinary System by US Government is in the public domain.

Figure 2.23 Closed_Urinary_Drainage by BruceBlaus is used under a CC-BY SA license.

Figure 2.24 Genital Herpes by SOA Amsterdam  is used under a CC- BY SA license.

Figure 2.25 Nephrostomy by United States Department of Health and Human Services is in the public domain.

19

2.11 Head-to-Toe Assessment: Musculoskeletal Assessment

Checklist 21 provides a guide for objective and subjective data collection in a musculoskeletal assessment


Checklist 21: Musculoskeletal Assessment

Figure 2.26 Muscular system
Figure 2.27 Skeletal system
Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Document according to agency guidelines

Objective Data

Consider the following observations.

Steps

Additional Information

Observe ability to maintain trunk in upright position, mobility, assistive devices, bruising, curvature or abnormalities of the spine, presence of casts, braces, or splints. General ability to move one’s body and maintain upright position reveals information about muscle strength and need for assistance with mobility needs.

Assistive devices should be in safe working order. Observe the patient’s ability to use these safely. See Chapter 3.5 Assistive Devices.

Any need for assistance, including mobility aids, should be included in the plan of care.

Observe range of motion (ROM) of upper and lower extremities. Limitations in ROM may suggest articular disease or injury.

CWMS (colour, warmth, movement, sensation) assessment encompasses many systems and is a quick way to rule out concern(s).

 

View Assessing Range of Motion and Strength by Candace Walker and Wendy McKenzie Thompson Rivers University.

Inspect arms and legs for pain, deformity, edema, pressure areas, and bruises. Unexpected findings should be followed with more detailed history and assessment, and reported to the appropriate healthcare provider.

Compare limbs bilaterally.

Assess motor power through hand grips, dorsi and plantar flexion, and knee and hip flexion against resistance.

 

General arm and hand strength can be assessed by asking the patient to extend their arms and grip the nurse’s hands simultaneously.

 

Apply slight resistance to top surface and ask patient to push against resistance.

 

Apply slight resistance to bottom of arms and ask patient to push against resistance.

 

Repeat with other arm

 
Figure 2.28 Assessing arm strength using resistance
Figure 2.29 Assess leg strength using resistance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asymmetrical findings may suggest underlying conditions, injury, effects of some medications, or post surgical complications.

 

General leg strength can be assessed by asking the patient to dorsiflex while the nurse applies some resistance to the bottom of the feet. Plantar flexion strength can be assessed by asking the patient to pull-up on their feet while the nurse applies some resistance to the top of the feet. Have the patient elevate one leg to 30 degrees and hold. Apply slight resistance to top surface and ask patient to push against resistance. Apply resistance to the bottom surface and ask the patient to push against resistance. Repeat with other leg.

Figure 2.30 assess strength of dorsi flexion

Figure 2.31 Assess leg strength against resistance
Palpate limbs for abnormality. Signs and symptoms of DVT include unilateral edema, pain, redness, and warmth at the site.

Any abnormalities or concerns should be reported to the appropriate healthcare provider.

Subjective Data

Ask about pain function, activity levels, joint problems, medications, and previous injury to extremities that may influence assessment findings.

Focused musculoskeletal assessment may include:

Determine Weight Bearing Status Check orders for weight bearing status if applicable. Some surgeries require the patient to be non- or partial weight bearing afterward to optimize healing.

For example: non-weight bearing, partial weight bearing, feather weight bearing.

Falls Risk Assessment: Falls occur as a result of losing balance or inability to regain balance. A number of risk factors can be considered when predicting risk some of which are not modifiable (age) and others modifiable (diet, exercise, poor vision). Risk assessment tools help healthcare providers to predict risk and are the starting point of  implementing strategies to reduce risk as much as possible.  Falls risk assessment is a routine part of nursing care in residential and acute settings. Communicate risk and appropriate interventions with the healthcare team and according to agency guidelines.

See:

Be aware of your agency’s guidelines to reduce risk of falls and injury related to falls.

Mobility Risk Assessment See Chapter 3.3 Risk Assessment for Safer Patient Handling
Motor Strength: Using an objective scale
Sample Motor Assessment Associated with Epidural Analgesia
0 No motor block: No intervention required.
1 Able to flex knees, but weak
2 Able to flex ankles. Can not flex knees
3 Cannot move ankles or knees
Adapted from OLCHC, 2016

Follow your agency guideline for the specific motor strength assessment scale used at your facility.

Potential nursing diagnoses:
  • Deconditioning related to immobility
  • Risk of falls
  • Altered mobility

 

Data Source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; OLCH, 2016; Perry et al., 2018; Potter et al, 2019;  Safer Health Care Now, 2015; Stephen et al., 2012; Wilson & Giddens, 2013

Potential musculoskeletal related nursing diagnoses:
  • Deconditioning related to immobility
  • Risk of falls
  • altered mobility due to
Data sources: Assessment Skill Checklists, 2014; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; OLCHC, 2016; Perry et al., 2018; Potter, Potter, & Ostendorf, 2019; Safer Health Care Now, 2015; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. Identify three strategies to reduce falls risk in a client with unlimited mobility.
  2. Besides nursing, identify interdisciplinary roles that can assist patients with mobility issues.

Attributions:

Figure 2.26 Muscular System by Termininja is used under a  Creative Commons Attribution-Share Alike 3.0 Unported license.

Figure 2.27 Diagram of a Human Female Skeleton by LadyofHats Mariana Ruiz Villarreal has been released into the public domain by its author via Wikimedia.

20

2.12 Head-to-Toe Assessment: Integument Assessment

Checklist 22 provides a guide for objective and subjective data collection in an integument assessment.

Checklist 22: Integument Assessment

Figure 2.32 Integumentary system
Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Document according to your agency’s policies and guidelines.

Objective Data

Consider the following:

Steps

Additional Information

 
  • Observe the skin from head to toe for colour, moisture, temperature, hair loss
Abnormalities in skin / sclera colour may indicate other health issues (i.e., jaundice)
Figure 2.33 Jaundiced sclera

Consider causes of excessive moisture. Excess moisture may increase the patient’s risk for skin breakdown.

Excessive temperature may indicate infection. Further assessment is required.

  • Observe condition of nails, eyes, and mucous membranes of nose and mouth
Neglect of nails may suggest difficulty with managing activities of daily living.

Fungal infection of nails is common.

Figure 2.34 Fungal nail infection (resolving)
  • Observe condition of mouth (evidence of oral care or lack thereof)
Figure 2.36   oral herpes
Figure 2.35 Oral candida
  • Mucous membranes of the mouth should be moist. Lack of moisture may suggest dehydration. Further assessment is required.
  • Poor oral health can be evidence of larger health or social issues. Further assessment is required.
  • Oral candida can occur with antibiotic therapy and from inhaled corticosteroids.
  • Oral care should be a routine part of every patient’s care plan.
  • Herpes infections are contagious. Risk assessment and implementation of PPE should be considered.
  • Assess skin integrity for presence of lesions, rashes, or pressure injury.
The integumentary system is our body’s first line of defense against invading organisms. Breaks in integument increase one’s risk of infection. Any concerns should be reported to the appropriate healthcare provider immediately.
Figure 2.37 Scabies
Figure 2.38 Gangrene
  • Inspect dressings and/or entry sites of all tubes, drains, and IVs.

 

Determine the rationale for all tubes. Tubes should be secured, intact, and functioning. See Table 10.1 Guidelines for Caring for Patients with Tubes and Devices.

Dressings should be dry and intact.

  • Note the amount, colour, and consistency of drainage from any tube.
The character of drainage provides insight into activities within the body.

Subjective Data

Ask if they have noticed any recent changes to their skin.

Focused integument assessment may also include:

Pressure Injury Risk Assessment

Braden scales for measuring risk of developing a pressure injury are widely used in North America in the adult patient population. The tool consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Using each of these elements, the nurse assigns a score. Low numbers translate to high risk of pressure injury.

 

See Braden Pressure Ulcer Risk Assessment

Some agencies have guidelines about frequency of assessment and documentation using a Braden Scale.

It is important for the nurse to remember that the Braden Scale is an assessment tool. The nursing process isn’t completed unless risk is addressed through preventative strategies and evaluation of outcomes.

Necessary interventions to prevent and treat pressure injury should be included in the plan of care.

Wound Assessment See 4.2 Wound Healing and Assessment
Potential integument related nursing diagnoses:
  • Impaired skin integrity due to incontinence.
  • Risk of pressure injury due to immobility.
  • Risk of wound infection due to contamination of coccyx wound with fecal matter.
Data sources: Braden & Bergstrom, 1989; RNAO, 2016; Potter et al., 2019

Critical Thinking Exercises

  1. Identify the six components of the Braden Scale that suggest risk of pressure injury.
  2. In five of those components, provide two possible preventative strategies to reduce risk of pressure injury.

Attribution:

Figure 2.32 Layers of Skin by Madhero88 and M. Komorniczak is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.
Figure 2.33 Jaundice Caused by Hepatitis A by CDC/Dr. Thomas F. Sellers/Emory University is in the public domain.
Figure 2.34 A Patient’s Left Foot – After Ten Weeks of Terbinafine Oral Treatment by Dandandandandandandan2014 is used under a Creative Commons Attribution-Share Alike 4.0 International license.
Figure 2.35 Thrush in a Child Who Has Taken Antibiotics by James Heilman, MD is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.
Figure 2.36 Herpes Labialis by Jojo is in the public domain.
Figure 2.37 Scabies by Cixia is in the public domain.
Figure 2.38 Gangrene Toe by James Heilman, MD is used under a CC BY-SA license.

21

2.13 Quick Priority Assessment (QPA)

Sometimes the nurse will not have time to complete a detailed assessment on every client at the start of the shift. Quick priority assessments provide a guide for the nurse to quickly gather information to help in determining relative client stability and priorities for care. This approach is also helpful each time the nurse interacts with the client and in the event of an emergency. Any concerns are followed up with a more focused assessment and, if necessary, activation of the agency’s emergency response system.

The QPA assessment includes the steps in Checklist 23.

Checklist 23: Quick Priority Assessment

Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.

 

Steps

Additional Information

A Airway. Does the patient’s position allow their airway to be patent? For example, if someone has slumped down in the bed or wheelchair, they may require repositioning.
B Breathing. What is the quality of the breathing? Are there any suggestions that breathing is compromised? Any concerns require further investigation.
C Circulation. What is the patient’s colour. Quickly palpate extremities for warmth. Any concerns require further investigation.
I In. What is going in? Identify every solution going into the patient. Follow all tubes from their source to the patient. Are the volumes adequate? Are the rates accurate? Are the tube insertion sites intact and free of complications? Is the safety equipment (i.e., pumps) plugged in and working? Is there any evidence of complications?
O Out. What is coming out? Are dressings dry and intact? Are any drainage tubes present? If so, what is the nature of the drainage? Follow all tubes from their source to the patient. Are the tubes patent? Are the tubes secured to avoid accidental or unintentional removal? Is there any evidence of complications?
P Pain. Is the patient comfortable? Are analgesics given previously still effective? Does the patient need repositioning? Are they too warm or too cold? Do they need to use the washroom?
Safety
  • Is the oxygen and suction equipment present and working?
  • Are the side rails up?
  • Are the patient’s belongings and call bell within reach?
  • Are restraints applied correctly?
  • Are the bed or wheelchair brakes applied?
  • Is the area clutter free?
  • Does the patient have a clear path to the washroom?
  • Always ask “is there anything you need from me at this time?”
Adapted from: Christensen & Kockrow, 1999

Critical Thinking Exercises

  1. Initial assessment of your patient reveals that the patient is having trouble speaking. What would be your next steps?
  2. Your patient is returning from surgery following an appendectomy. Outline an assessment plan using a systems approach

22

2.14 Summary

Key Takeaways

  • Assessment is a cornerstone of nursing care.
  • Whatever approach nurses take with assessment, it is important to approach assessment methodically and to consider objective and subjective information sources.

 

References

Alberta Health Services. (2009). Instructions for administration of minimental state examination (MMSE).  Retrieved http://www.palliative.org/NewPC/_pdfs/tools/MMSE%20administration.pdf

Anderson, B., Nix, N., Norman, B., & McPike, H. D. (2014). An evidence based approach to undergraduate physical assessment practicum course development. Nurse Education in Practice, 14(3), 242-246.

Assessment Skill Checklists. (2014). Checklists from Nursing 1019: Clinical Techniques (BCIT BSN program course).

British Columbia College of Nursing Professionals [BCCNP]. (2018). Scope of Practice for Registered Nurses. Retrieved https://www.bccnp.ca/Standards/RN_NP/StandardResources/RN_ScopeofPractice.pdf

BCGuidelines.ca (2014). Standardized Mini – Mental State Examination (SMMSE). From Cognitive Impairment – Recognition, Diagnosis and Management in Primary Care: Standardized Mini-Mental State Examination. Retrieved https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/cogimp-smmse.pdf

Braden B. &  Bergstrom N. (1989). Clinical utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus, 2. pp. 44-51. Retrieved http://www.health.alberta.ca/documents/AADL-Braden-Assessment.pdf

Brodovicz, K., McNaughton et al., (2009). Reliability and Feasibility of Methods to Quantitatively Assess Peripheral Edema. Clincal Medicine and Research. Retrieved http://www.clinmedres.org/content/7/1-2/21.full

Christensen & Kockrow (1999). Foundations of Nursing (3rd ed.). St. Louis: Mosby. Retrieved http://www.cabrillo.edu/~ttaylor/Prep_forms/Quick%20Patient%20Assessment.pdf

Critical Care Services Ontario. (2014). Guidelines for Basic Adult Neurological Observation. https://www.criticalcareontario.ca/EN/Neurosurgical%20Care/Guidelines%20for%20Basic%20Adult%20Neurological%20Observation%20(2014).pdf

Davis, C., Chrisman, J., Walden, P.  (2012). To scan or not to scan. Nursing Made Incredibly Easy! 10(4). Pp.53–54. doi: 10.1097/01.NME.0000415016.88696.9d

Retrieved https://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2012/07000/To_scan_or_not_to_scan__Detecting_urinary.13.aspx

Hill, D. & Smith, R. (1990). Chapter 30Examination of the Extremities: Pulses, Bruits, and Phlebitis. In Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. H. Walker & J. Hurst Eds. Boston: butterworths. Retrieved https://www.ncbi.nlm.nih.gov/books/NBK350/

Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2014). Physical examination and health assessment. Toronto, ON: Elsevier-Saunders.

Lapum, J., Verkuyl, M., Garcia, W., St-Amant, O., Tan, A. (2018). Vital Sign Measurement Across the Lifespan – 1st Canadian edition. Ryerson University. Retrieved https://opentextbc.ca/vitalsign/

Lloyd H. &  Craig S. (2007). A guide to taking a patient’s history. Nursing Standard, 22(13), pp. 42-28. Retrieved https://www.researchgate.net/publication/5610987_A_guide_to_taking_a_patient’s_history

Our LadyChildrensHospital Crumlin [OLCHC]. (2016). Epidural Assessment. Retrieved

http://www.olchc.ie/Healthcare-Professionals/Nursing-Practice-Guidelines/Epidural-Assessment-Sheet-2016.pdf

Pasero, C., (2009). Assessment of Sedation During Opioid Administration for Pain Management. Journal of PeriAnesthesia Nursing, Vol 24, No 3 (June), 2009: pp 186-190. Retrieved http://www.mghpcs.org/eed_portal/Documents/Pain/Assessing_opioid-induced_sedation.pdf

Perry, A., Potter, P., & Ostendorf, W. (2018). Clinical skills and nursing techniques (9th ed.). St Louis, MO: Elsevier-Mosby.

Potter, P., Perry, A., Stockert, P., Hall., Astle, B., Duggleby, W. (2019). Canadian Fundamentals of Nursing. 6th Edition. Milton  Ontario: Elsevier.

RNAO (nd). Nursing Best Practice Guideline: Outline of a mental status examination. Retrieved http://pda.rnao.ca/content/outline-mental-status-assessment

Registered Nurses Association of Ontario [RNAO]. (2013). Assessment and management of pain: Best practice guidelines. Retrieved  https://rnao.ca/sites/rnao-ca/files/AssessAndManagementOfPain_15_WEB-_FINAL_DEC_2.pdf

RNAO (2016). Clinical Best Practice Guideline: Assessment and Management of Pressure Injuries for the Interprofessional Team. Third Edition. Retrieved

https://rnao.ca/sites/rnao-ca/files/PI_BPG_FINAL_WEB_June_10_2016.pdf

Rosdahl, C. B., & Kowalski, M. T. (2007). Textbook of basic nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

Royal Children’s Hospital Melbourne [RCH]. (2015). Assessment of dermatome block. Retrieved https://www.rch.org.au/anaes/pain_management/Assessment_of_sensory_block/

Royal  Children’s Hospital Melbourne [RCH] (2017). Clinical Guidelines Nursing: Assessment. Retrieved https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/

Safer Health Care Now. (2015). Reducing falls and injuries from falls. Retrieved http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Getting%20Started%20Kit.pdf

Stephen, T. C., Skillen, D. L., Day, R. A., & Jensen, S. (2012). Canadian Jensen’s nursing health assessment: A best practice approach. Philadelphia, PA: Wolters Kluwer-Lippincott.

Wilson, S. F., & Giddens, J. F. (2013) Health assessment for nursing practice (5th ed.) St Louis, MO: Mosby.

III

Chapter 3. Safer Patient Handling, Positioning, Transfers and Ambulation

23

3.1 Introduction

In healthcare, all patient-handling activities, such as positioning, transfers, and ambulation, are considered high risk for injury to patients and healthcare providers. This chapter reviews the essential guidelines for proper body mechanics and safe transfer techniques to minimize and eliminate injury in healthcare.

Learning Outcomes

  • Describe body mechanics and principles of body mechanics.
  • Define musculoskeletal injury (MSI).
  • Discuss factors that contribute to an MSI, and ways to prevent an MSI.
  • Discuss risk assessment and four areas of attention required when moving patients.
  • Describe how different levels of assistance affect decisions about assisting with mobility and transfers.
  • Describe various techniques for positioning a patient in bed and types of positions.
  • Describe the process of a one person transfer assist from bed to a wheelchair including the use of any assistive device.
  • Describe how to transfer a patient from a stretcher to a bed using an assistive device.
  • Discuss situations where mechanical assistive devices are necessary when moving patients.
  • Discuss falls prevention strategies.

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3.2 Body Mechanics

Body mechanics involve the coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during moving, transferring, and positioning patients. Proper body mechanics allows individuals to carry out activities without excessive use of energy, and it helps prevent injuries for patients and health care providers (Perry, Potter, & Ostendorf, 2018).

Musculoskeletal Injuries

A musculoskeletal injury (MSI) is an injury or disorder of the muscles, tendons, ligaments, joints or nerves, blood vessels, or related soft tissue including sprains, strains, or inflammation related to a work injury. MSIs are the most common health hazard for healthcare providers (WorkSafeBC, 2013). Table 3.1 lists risk factors that contribute to MSI.

Table 3.1 Factors that Contribute to MSIs

Factor

Special Information

Ergonomic risk factors Force: Lifting, lowering, carrying, pushing, pulling, and grip all involve force. Strong forces and light forces present risk for MSI.

Repetition: Refers to using the same group of muscles to complete a task over and over with little time for muscles to recover.

Work posture: The position of different parts of the body, particularly awkward positions, can exert force on the muscles and bones, which causes strain. When a joint bends excessively or awkwardly, or outside its range of motion, MSI can occur. This also includes static postures. Workers need to change their body posture and move about periodically.

Local contact stress: Refers to when hard or sharp objects come in contact with the skin, and the nerves and tissues become damaged by pressure.

Individual risk factors Poor work practice; poor overall health (smoking, drinking alcohol, and obesity); poor rest and recovery; poor fitness, hydration, and nutrition
Data sources: Perry et al., 2018; WorkSafeBC, 2008; WorkSafeBC, 2013

When healthcare providers are exposed to ergonomic risk factors, they become fatigued and risk musculoskeletal imbalance. Additional exposure related to individual risk factors puts healthcare providers at increased risk for MSI (WorkSafeBC, 2013). Preventing MSIs is achieved by understanding the elements of body mechanics; applying the principles of body mechanics to all work-related activities; understanding how to assess a patient’s ability to position or transfer; and learning safe handling transfers and positioning techniques.

Elements of Body Mechanics

Body movement requires coordinated muscle activity and neurological integration. It involves the basic elements of body alignment (posture), balance, and coordinated movement. Body alignment and posture bring body parts into position to promote optimal balance and body function. When the body is well aligned, whether standing, sitting, or lying, the strain on the joints, muscles, tendons, and ligaments is minimized (WorkSafeBC, 2013).

Body alignment is achieved by placing one body part in line with another body part in a vertical or horizontal line. Correct alignment contributes to body balance and decreases strain on muscle-skeletal structures. Without this balance, the risk of falls and injuries increases. In the language of body mechanics, the centre of gravity is the centre of the weight of an object or person. A lower centre of gravity increases stability. This can be achieved by bending the knees and bringing the centre of gravity closer to the base of support, keeping the back straight. A wide base of support is the foundation for stability and is achieved by placing feet a comfortable, shoulder-width distance apart. When a vertical line falls from the centre of gravity through the wide base of support, body balance is achieved. If the vertical line moves outside the base of support, the body will lose balance.

The diagram in Figure 3.1 demonstrates: (A) a well-aligned person whose balance is maintained and whose line of gravity falls within the base of support; (B) balance is not maintained when the line of gravity falls outside the base of support; and (C) balance is regained when the line of gravity falls within the base of support.

Figure 3.1 Centre of gravity

Principles of Body Mechanics

Table 3.2 describes the principles of body mechanics that should be applied during all patient-handling activities.

Table 3.2 Principles of Body Mechanics

Action

Principle

Assess the environment. Assess the weight of the load before lifting, and determine if assistance is required.
Plan the move. Plan the move; gather all supplies; and clear the area of obstacles.
Avoid stretching and twisting. Avoid stretching, reaching, and twisting, which may place the line of gravity outside the base of support.
Ensure proper body stance. Keep stance (feet) shoulder-width apart.

Tighten abdominal, gluteal, and leg muscles in anticipation of the move.

Stand-up straight to protect the back and provide balance.

Stand close to the object being moved. Place the weight of the object being moved close to your centre of gravity for balance.
Hold objects close to your centre of gravity
Hold objects close to your centre of gravity
Figure 3.2 Note the caregiver’s center of gravity and proximity to the patient

Remain as  close to the person as possible when you are about to transfer. Use the long and strong muscles of arms and legs, not the back muscles.

Face direction of the movement. Facing the direction prevents abnormal twisting of the spine.
Avoid lifting. Turning, rolling, pivoting, and leverage requires less work than lifting.

Do not lift if possible; use mechanical lifts as required.

Encourage the patient to help as much as possible.

Note: Many agencies have “no lift” policies.

Work at waist level. Keep all work at waist level to avoid stooping.

Raise the height of the bed or object if possible.

Do not bend at the waist.

Reduce friction between surfaces. Reduce friction between surfaces, so that less force is required to move the patient.

Special sliding sheets can be used to ease patient transfers or positioning.

Bend the knees. Bending the knees maintains your centre of gravity and lets the strong muscles of your legs do the lifting.
Push the object rather than pull it, and maintain continuous movement. It is easier to push an object than to pull it.

Less energy is required to keep an object moving than to stop and start it.

Use assistive devices. Use assistive devices (gait belt, slider boards, mechanical lifts) as required to position patients and transfer them from one surface to another.
Work with others. The person with the heaviest load should coordinate all the effort of the others involved in the handling technique.
Data sources: Berman & Snyder, 2016; Perry et al., 2018; Registered Nursing, n.d.; WorkSafeBC, 2013

Critical Thinking Exercises

  1. How do body alignment and body balance contribute to proper body mechanics?
  2. John is asked to transfer a client from the bed to a stretcher. Name five principles of body mechanics John can implement to prevent a MSI.

Attributions

Figure 3.2 An illustration depicting how to transfer someone using the pivot method by BruceBlaus is used under a CC BY-SA 4.0 license.

25

3.3 Risk Assessment for Safer Patient Handling

Risk Assessment for Safer Patient Handling

To prevent and minimize MSI injuries related to patient handling activities, a risk assessment must be done to determine a patient’s ability to move, the need for assistance, and the most appropriate means of assistance (Provincial Health Services Authority [PHSA], 2010). There are four important areas to assess:

Checklist 24 outlines these four areas of assessment and what to consider prior to positioning, ambulation, and transfers.

Checklist 24: Risk Assessment for Safer Patient Handling.

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
  • The assessment process should not override clinical judgment and patient-specific needs as determined by the healthcare team.
  • An assessment should be performed before each handling procedure.
  • Seek additional help if a procedure requires two or more persons.
  • Use assistive devices (gait belts, slider boards, pillows, etc.) to perform the procedure safely.
  • Assess the patient’s ability to tolerate the movement. Acute pain, shortness of breath, and inability to follow direction will place the healthcare provider and patient at risk for injury.
  • Always consider the principles of proper body mechanics prior to any procedure, such as raising the head of bed and tucking elbows in to help prevent injuries.
  • Avoid lifting shoulders when positioning a patient.
  • Never lift a patient; always use a weight shift to perform the procedure.
  • When positioning a patient using a sheet, place palms of hands up. A palms-down technique increases risk for injury.
  • Vision and hearing loss, and language barriers can make communicating with the patient difficult and can result in increased risk for injury.
  • Ensure the plan of care is updated regularly.

Steps

Additional Considerations

1. Assess your patient. There are three areas to assess:

1. Is the patient cooperative and able to follow directions?

Ask patient to squeeze your hands. Is the behaviour predictable (non-aggressive, fearful, or fatigued)? Is the patient able to follow directions with cues?

  • If yes, proceed to next question.
  • If no, use a mechanical lift for transfers and/or assistive devices for repositioning in bed if patient has some abilities.

2. Can the patient bear weight?

Ask patient to lift buttocks off the bed (also known as “bridging”) and hold the position for five seconds. The healthcare provider may give cues on how to lift buttocks off the bed.

Bridging hips strength test
Bridging hips strength test

After bridging, ask the patient to perform a straight leg raise by lifting one leg up off the bed and holding it for five seconds while the other leg is kept bent. Repeat with the opposite leg.

Leg lift strength test
Leg lift strength test
  • If yes, proceed to next question.
  • If no, use an appropriate moving technique, such as a mechanical lift and/or assistive device, to transfer a non-weight-bearing patient.

3. Can the patient sit up on the side of the bed without support? Can the patient sit forward on a chair or the edge of the bed without support?

Sit unassisted on the bed
Sit unassisted on the bed
  • If yes, decide on the amount of assist required (minimum, moderate, or maximum) according to your agency policy.
  • If no, use a mechanical lift for transfers and/or an assistive device for repositioning if patient has some movement abilities.

Risk assessment also involves knowing any activity restrictions associated with recent surgery or injury.

2. Assess your environment. Is there adequate space?

Is available equipment in proper working order?

Have all hazards been removed?

3. Assess yourself and readiness to perform procedures. Complete all required training according to health agency regulations.

Wear non-slip footwear.

Maintain a neutral spine; do not twist or side bend; and use proper body mechanics when moving or positioning patients.

Designate a leader if working in a team to mobilize or position a patient.

Always use proper weight-shift techniques (side to side, front to back, and up and down).

4. Assess your work organization. Ensure adequate number of caregivers.

Ensure there is enough time to perform the procedure.

Take rest breaks and vary activities to promote optimal back health.

If patient is complex or bariatric, consult additional resources, seek assistance, and use assistive devices.

Data sources: Interior Health, 2013; National Institute of Occupational Safety and Health, 2010; PHSA, 2010; WorkSafeBC, 2010

The following are useful resources to help you further develop your understanding of assessment and decision making around  patient handling activities.

Read the Mobility Decision Support Tool flowchart, which was provincially developed, to guide decision making about transfers and ambulation.
Watch the Assess Every Time video, which was developed by WorkSafeBC, to review the quick assessment as described in Checklist 24.
Here is a sample of a Safe Patient Handling Assessment Form from the Winnipeg Region Health Authority (2015).

Critical Thinking Exercises

  1. Name five things the healthcare worker should assess about themselves when considering their own ability to perform a patient-handling procedure?
  2. Vision and hearing impairments, as well as language barriers, are risk factors when performing patient-handling procedures. What additional patient risk factors should be considered?

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3.4 Levels of Assistance

Some patient conditions result in a decreased ability to perform activities of daily living including one’s ability to be mobile. Some patients may require assistance to move around in bed, or to transfer from bed to wheelchair or bed to stretcher. Others may need assistance to ambulate. Changing patient positions in bed and mobilization are also vital to prevent contractures from immobility, maintain muscle strength, prevent pressure injury, and to help body systems function properly for optimal health and healing (Perry et al., 2018). The amount of assistance each patient will require depends on the patient’s previous health status, age, type of illness, and length of stay (Perry et al., 2018).

General Description—Levels of Assistance

Commonly in acute and residential care settings, patients are assessed and assigned with a “level of assistance” designation. The level of assistance required is based on the patient’s ability to transfer, stand, and cooperate in care activities. Terms to describe different levels of assistance are one way for health care providers to communicate with each other how much and what kind of assistance is required.

The terms may differ from one institution to the next and as such it is the healthcare provider’s responsibility is to know the correct terms in the institutions they are working in (South Island Alliance, n.d.). The level of assistance needed is somewhat subjective can change over time. Thus, the need for constant reassessment and communication by and among the healthcare team (South Island Alliance, n.d.).

The level of assistance should be documented where healthcare providers can easily access the information. This might include the patient’s Kardex, above the head of the bed, and/or in the patient’s chart. Table 3.3 describes general levels of assistance and the terminology sometimes used in hospital and community settings to describe them.

Table 3.3 General Levels of Assistance

Level of Assistance Terminology

Criteria

 Independent The patient:
  • is able to transfer independently and safely.
Standby Supervision / One Person Assist
  • requires no physical assistance but may require verbal reminder.
  • may also be learning to transfer independently using a wheelchair, walker, or cane.
Minimal Assist / One Person Assist
  • is cooperative and reliable, but needs minimal physical assistance with the transfer.
  • requires minor physical exertion from healthcare worker during re-positioning, assisting to stand / sit, and when ambulating.
  • can consistently fully weight bear when standing.
  • is able to perform 75% of the required activity on their own.
Two Person Assist
  • requires more than minor physical assistance.
  • often needs equipment to assist with transfers or mobilization.
  • is able to perform 50% of the required activity on their own.
Total Assist
  • requires full physical assistance for re-positioning, standing, turning, transfers, and/or mobility.
  • may be unpredictable and uncooperative.
  • requires equipment to assist with re-positioning and transfers
  • is able to perform 0-25% of the required activity on their own.
Data sources: South Island Alliance, n.d.; Winnipeg Regional Health Authority (WRHA), 2008; Worksafe BC, 2006
Special considerations:
  • The weight, height, and general physical, mental, or emotional condition of the patient all influence the potential for injury to the patient and healthcare worker.
  • If the patient is uncooperative or unable to follow commands, there is an increased risk for injury. In these cases, a mechanical lift or assistive device should be used to prevent injury to the healthcare provider and/or patient.
  • Any patient-handling injuries must be reported using the British Columbia Patient Safety and Learning System (BCPSLS), a web-based tool used to report and learn about safety events, near misses, and hazards in healthcare settings (BCPSLS Central, 2015).

Critical Thinking Exercises

  1. A patient requires no assistance from the healthcare provider except for the occasional reminder to lift their feet while walking. What level of activity designation would you give to this patient?
  2. A patient is assessed as needing a one-person pivot transfer. As the healthcare provider begins the transfer, the patient suddenly becomes uncooperative. What should the healthcare provider do next?

27

3.5 Assistive Devices

An assistive device is an object or piece of equipment designed to help a patient with activities of daily living, such as a walker, cane, gait belt, or mechanical lift (WHO, 2018). Assistive devices also allow the the healthcare worker to transfer and move patients in a way that reduces risk for injury to themselves and patients. Table 3.4 lists some assistive devices found in the hospital and community settings that can be used to help transfer patients in and out of bed and within the bed.

Table 3.4 Assistive Devices to Help Transfer Patients In and Out of Bed and Within the Bed

Type

Definition

Gait belt or transfer belt Used to ensure a good grip on potentially unstable patients. The device provides added stability when transferring patients. It is a 5 mm (2 in) wide belt, with or without handles, that is placed around a patient’s waist and fastened with Velcro. The gait belt must always be applied on top of clothing or gown to protect the patient’s skin. A gait belt can be used with patients in both one-person or two-person pivot transfer, or in transfer with a slider board.
Gait Belt
Gait belt
Slider board (stretcher board)
Slider board (red) on a stretcher
Slider board (red) on a stretcher
SliderBoard2 (1)
Placing a slider board (transfer board) under a patient

A slider board is used to transfer immobile patients from one surface to another while the patient is lying supine. The board assists healthcare providers move immobile, bariatric, or complex patients more safely.

Mechanical lift A mechanical lift is a hydraulic lift, usually attached to a ceiling, used to move patients who cannot bear weight, who are unpredictable or unreliable, or who have a medical condition that does not allow them to stand or assist with moving.
Mechanical lift
Mechanical lift
Air transfer mattress Using air assisted technology, air transfer mattresses allow caregivers to easily reposition and transfer patients laterally (i.e., bed to stretcher and vice versa). See: Product information for HoverMatt Air Transfer System.
Slider sheets Nylon sheets used under the patient. Sometimes the nylon is the undersurface of the transfer sheet. Sometimes a combination of a transfer sheet’s nylon surface in contact with a nylon surface fitted bed sheet can help to reduce friction during patient moves in bed.
Figure 3.3 Slider sheet / turning sheet
Monkey bar (a.k.a., medical trapeze) A trapeze positioned above the patient near the head of the bed allows the patient to grasp and reposition themselves or to help with re-positioning. The trapeze can be fixed to the bed or free standing. They are contraindicated in some situations including new spinal cord injury, post abdominal surgery, and shoulder conditions.
Figure 3.4 bed trapeze / monkey bar
Sit to stand lift Device used to assist patients from a sitting to standing position.
Figure 3.5 Sit to stand mechanical lift
Transfer board Transfer boards (not to be confused with a slider or stretcher board) are small pieces of rigid wood or plastic used to bridge the gap between two surfaces. For example, between a wheelchair and a bed.

When a patient is initially learning to use a transfer board, one to two healthcare workers may use a gait belt to assist. Eventually some patients are able to transfer independently from a wheelchair to bed using a transfer board.

Figure 3.6 Slider board for transferring bed to chair and vice versa
Data sources: HoverTech International, 2016; Perry et al., 2018.
Special considerations:

Critical Thinking Exercise

  1. A 100 kg patient with limited mobility requires transfer from his bed to stretcher. The nurse chooses to use a HoverMatt© air transfer mattress for the transfer. Describe how this technology limits musculoskeletal strain, and give the steps for its use in this situation.

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3.6 Types of Patient Transfers

Transfers involve moving a patient from one flat surface to another, such as from a bed to a stretcher (Perry et al., 2018). Types of hospital transfers include bed to stretcher, bed to wheelchair, wheelchair to chair, and wheelchair to toilet, and vice versa. Table 3.5 outlines types of transfers and patient factors that help to determine appropriateness of each.

Table 3.5 Types of Transfers

Type of Transfer

Appropriateness

One-person standing pivot The patient:
  • can bear weight on one or both legs.
  • is cooperative and predictable.
  • can sit with minimal support on the side of the bed.

Note: A gait belt may or may not be used.

Two-person standing pivot
  • can assist with weight bearing, but may be inconsistent.
  • is cooperative and predictable.

Note: Two-person transfer with a gait belt, a stander, or a two-person transfer with a slide board and a gait belt may be used.

One-person assist with transfer board
  • is cooperative, follows directions, and has good trunk control.
  • can use their arms, but cannot bear weight on both legs.
Two-person assist with transfer board
  • is cooperative and can follow directions.
  • can use their arms, but cannot bear weight on both legs.
  • does not have good trunk control.

Note: If transferring out of a wheelchair, the chair must have removable arms.

Sit-to-stand
  • can actively participate, with some ability to stand.
  • is reliable.
  • is predictable.
  • is a heavy two-person transfer.
  • does not have severe limb contractures or injuries where movement is medically contraindicated (e.g., spinal injury).
Mechanical / ceiling track
  • cannot reliably stand.
  • is unpredictable.
  • is too heavy for a two-person transfer.
Data sources: WorkSafeBC, 2006; WRHA, 2008
Review this Mobility Decision Support Tool from Interior Health (n.d.).
Sections 3.7 and 3.8 offer more information about patient transfers with or without mechanical assistive devices.

29

3.7 Types of Patient Transfers: Transfers without Mechanical Assistive Devices

Patient Transfer from Bed to Stretcher

A bed to stretcher transfer requires a minimum of three to four people, depending on the size of the patient and the size and strength of the healthcare providers. Patients who require this type of transfer are generally immobile or acutely ill, so they may be unable to assist with the transfer. Checklist 25 shows the steps for moving patients laterally from one surface to another.

Checklist 25: Moving a Patient from Bed to Stretcher

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 

 

  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Inform the patient what is about to happen and how they can assist.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.
  • Ensure brakes are locked on the bed and stretcher.
  • A slider board and full-size sheet or friction-reducing sheet are required for the transfer.

Steps

 Additional Information

1. Always predetermine the number of staff required to safely transfer a patient horizontally.

Three to four healthcare providers are required for the transfer.

2. Explain what will happen and how the patient can help (tucked-in chin, keep hands on chest).

Collect supplies.

This step provides the patient with an opportunity to ask questions and help with the transfer.

Slider board (red) on a stretcher
Stretcher and slider board
Chin tucked in and arms across chest
Chin tucked-in and arms across chest

3. Raise bed to safe working height. Flatten the head of bed and side rails.

Position the patient closest to the side of the bed where the stretcher will be placed.

Safe working height is at waist level of the shortest healthcare provider.

The patient must be positioned correctly prior to the transfer to avoid straining and reaching.

May need additional healthcare providers to move patient to the side of the bed.

4. Position stretcher beside the bed on the side closest to the patient with stretcher slightly lower. Apply brakes.

Caregiver #1 stands closest to the patient.

Caregiver #2 and #3 stand on the other side of the bed: #2 is at the head and shoulders, and #3 is at the hips and legs.

Caregiver #4 can be used to move feet or equipment, or help #2 and #3 with pulling.

The slider board will form a bridge between the bed and the stretcher.

The sheet must be between the patient and the slider board to decrease friction between patient and board.

Placing slider board
Place slider board

Ensure all tubes and attachments are out of the way.

5.  Caregiver #1 uses a front-to-back weight shift to roll patient onto their side using the sliding sheet.

Meanwhile, caregivers #2 and #3 climb onto and kneel on the bed to place the slider board halfway under the patient.

The patient is returned to the supine position.

Patient’s feet are positioned on the slider board.

 

Ensure proper body mechanics by keeping elbows close and backs tall.

The position of the healthcare providers keeps the heaviest part of the patient near the healthcare providers’ centre of gravity for stability.

Caregiver at the head of the bed
Caregiver at the head of the bed

6. Caregivers #2 and #3 can remain on the stretcher. They grasp the draw sheet using a palms up technique, sitting-up tall, and keeping their elbows close to their body and backs straight.

Caregiver #1 remains on the far side of the bed, between the chest and hips of the patient, with hands on hips and shoulders and forearms parallel to the bed.

 

Alternately, caregivers #2 and #3 can stand on the floor opposite to caregiver #1, grab the draw sheet using a palms up technique, and a front-to-back weight shift position.

 

7. The designated leader will count “1, 2, 3,” and start the move.

Caregiver #1 will push patient just to arm’s length using a back-to-front weight shift.

At the same time, caregivers #2 and #3 on the stretcher will move from a sitting-up-tall position to sitting on their heels, shifting their weight from the front leg to the back, bringing the patient with them using the sheet.

Coordinating the move between healthcare providers prevents injury while transferring patients.

Using a weight shift from front-to-back uses the legs to minimize effort when moving a patient.

8. Caregivers #2 and #3 will climb off the stretcher and stand at the side, and grasp the sheet keeping elbows tucked-in.

On the count of three, with backs straight and knees bent, they use a front-to-back weight shift and slide the patient into the middle of the bed.

The step allows the patient to be properly positioned in the bed and prevents back injury to healthcare providers.

Caregiver at the head of the bed
Caregiver at the head of the bed
Weight on front leg
Weight on front leg
Shift weight to back foot
Shift weight to back foot

9. At the same time, caregiver #1 pulls the slider board out from under the patient.

This step allows the patient to lie flat on the bed.

10. Replace pillow under head, ensure patient is comfortable, and cover the patient with sheets.

This promotes comfort and prevents harm to patient.

11. Lower bed. Raise side rails as required, and ensure call bell is within reach.

Perform hand hygiene.

Placing bed and side rails in a safe position reduces the likelihood of injury to patient. Proper placement of call bell facilitates patient’s ability to ask for assistance.
Bed in lowest position, side rail up, call bell within reach
Bed in lowest position, side rail up, call bell within reach

Hand hygiene reduces the spread of microorganisms.

Data sources: Perry et al., 2018; PHSA, 2010
Take PHSA’s Lateral Transfer Sliding Board course for more information on sliding board transfer.

Transfer from Bed to Wheelchair

Patients often need assistance when moving from a bed to a wheelchair. A patient must be cooperative and predictable, and able to bear weight on both legs and take small steps. If any of these criteria are not met, a two-person transfer or mechanical lift is recommended. Always complete a patient risk assessment prior to all patient-handling activities. See Checklist 26 for the steps to transfer a patient from the bed to the wheelchair (PHSA, 2010).

Checklist 26: Bed to Wheelchair Transfer—One Person Assist

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Inform the patient what is about to happen and how they can assist.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.
  • Ensure brakes are locked on the bed and stretcher.
  • A gait belt and wheelchair are required.

Steps

 Additional Information

1. Perform hand hygiene.

Explain what will happen during the transfer and how the patient can help.

This step provides the patient with an opportunity to ask questions and help with the positioning.

Explain procedure to patient

Explain procedure to patient

2. Apply proper footwear prior to ambulation.

Proper Footwear
Proper footwear

3. Lower the bed and ensure that brakes are applied.

Place the wheelchair next to the bed at a 45-degree angle and apply brakes.

If a patient has weakness on one side, place the wheelchair on the stronger side.

Ensure brakes are applied on the wheelchair.
Wheelchair with one leg rest removed
Wheelchair with one leg rest removed

4. Sit patient on the side of the bed with his or her feet on the floor. Apply the gait belt snugly around the waist (if required).

Place hands on waist to assist into a standing position.

The patient’s feet should be in between the healthcare provider’s feet.

5. As the patient leans forward, grasp the gait belt (if required) on the side of the patient, with your arms outside the patient’s arms. Position your legs on the outside of the patient’s legs.

The patient’s feet should be flat on the floor.

Rock back and forth to provide momentum
Assist to a standing position using a gait belt

6. Count to three and, using a rocking motion, help the patient stand by shifting weight from the front foot to the back foot, keeping elbows in and back straight.

Assist to standing position
Weight shift to back leg by healthcare provider

7. Once standing, have the patient take a few steps to the side and back until they can feel the wheelchair on the back of their legs.

Have patient grasp the arm of the wheelchair and lean forward slightly.

Ensure the patient can feel the wheelchair on the back of the legs prior to sitting down.
Assist into the wheelchair
Assist into the wheelchair

8. As the patient sits down, shift your weight from back to front with bent knees, with trunk straight and elbows slightly bent.

Allow patient to sit in wheelchair slowly, using armrests for support.

This allows the patient to be properly positioned in the chair and prevents back injury to healthcare providers.

Transferred to wheelchair
Transfer to wheelchair
 Data sources: Perry et al., 2018; PHSA, 2010
Special considerations:

2019 Update: some health authorities are no longer recommending the care giver be positioned directly in front of the patient being transferred. Instead, the care giver should stand to the side of the patient and use a gait belt or transfer belt to guide the patient.

See Interior Health (nd). Patient handling procedure: One person manual transfer  https://www.interiorhealth.ca/sites/Partners/WHSresources/Documents/Manual%20Transfers%20-%20One%20Person%20SWP.pdf

Watch the video Assisting from Bed to Chair with a Gait Belt or Transfer Belt (2018) by Kim Morris of Thompson Rivers University School of Nursing.

Take PHSA’s Standing Step Around Transfer (2010) course to learn the method for a bed to wheelchair transfer.

Critical Thinking Exercises

  1. Prior to moving the patient from bed to a wheelchair, where should the patient’s feet be placed?

30

3.8 Types of Patient Transfers: Transfers Using Mechanical Aids

Depending on the risk assessment, the healthcare worker may choose to use a mechanical aid to assist with transferring a patient. The following videos provide some general direction to do this. It is the nurse’s responsibility to be oriented to the equipment they are working with and always use it in a safe manner.

Watch the following videos (2018) by Kim Morris of Thompson Rivers University School of Nursing:

Sit to Stand Mechanical Assist

How to Use a Ceiling Lift

How to Use a Hammock Sling

How to Use a Hygiene Sling

Table 3.6 provides information about different kinds of slings used in the above videos.

Table 3.6: Choosing a Sling to Be Used with the Ceiling Lift

Type of Sling

Indications for Use

Universal slings
  • Can be applied while the client is sitting in a wheelchair.
  • Some universal slings are large enough to provide neck support.
  • Different loops allow the user to adjust the patient’s position (i.e., head up, flat, etc.).
  • Follow the manufacturer’s guidelines for use.
Hammock slings
  • Provide more support than a universal sling.
  • Fit from just above the knees to the back of the head, thus giving some neck support.
  • Cannot be taken off while the patient is in a wheelchair.
  • Different loops allow for adjustments to the angle that the user will sit during the transfer.
Hygiene slings
  • Intended to be used for transfers associated with toileting and cleaning.
  • Provide relatively little support, as they have less material than a universal or hammock sling.
  • Intended to provide patient support for a short time only.
Data source: Stewart, 2018
Special considerations:

Critical Thinking Exercises

  1. In the following situations, provide rationale for your choice of type of sling when using a ceiling lift: (a) transfer to a shower chair; (b) transfer to a wheelchair.

 

31

3.9 Positioning Patients in Bed

Positioning a patient in bed is important for maintaining alignment and for preventing pressure injury, foot drop, and contractures (Perry et al., 2018). Proper positioning is also vital for providing comfort for patients who are bedridden or who have decreased mobility related to a medical condition or treatment. When positioning a patient in bed, supportive devices such as pillows, rolls, wedges, and blankets, along with re-positioning, can aid in providing comfort and safety (Perry et al., 2018).

Positioning Patients in Bed

Positioning a patient in bed is a common procedure in the hospital. There are various positions possible for patients in bed, which may be determined by their condition, preference, or treatment related to an illness. Table 3.7 identifies patient positions in bed and a description for each.

Table 3.7 Patient Positions in Bed

Position

Description

Supine position Patient lies flat on back. Additional supportive devices may be added for comfort, i.e., under lower legs, under head.
Supine
Supine position
Prone position Patient lies on stomach with head turned to the side.
Prone
Prone position
Lateral position Patient lies on the side of the body with the top leg over the bottom leg. This position helps relieve pressure on the coccyx.
Lateral
Lateral position
Sims position Patient lies between supine and prone with legs flexed in front of the patient. Arms should be comfortably placed beside the patient, not underneath.
Sims
Sims position
Fowler’s position Patient’s head of bed is placed at a 45-degree angle. Hips may or may not be flexed. This is a common position to provide patient comfort and care.
High fowlers
Fowler’s position
  • high Fowler’s position is used to describe a patient’s position where the upper body is positioned approximately 60 and 90 degrees in relation to the lower body.
Semi-Fowler’s position Patient’s head of bed is placed at a 30-degree angle. This position is used for patients who have cardiac or respiratory conditions, and for patients with a nasogastric tube and who have enteral nutrition.
Semi- fowlers
Semi-Fowler’s position
Orthopneic or tripod position Patient sits at the side of the bed with head resting on an over-bed table on top of several pillows. This position is used for patients with breathing difficulties.
Figure 3.7 Tripod position – relieves restriction on rib cage and promotes lung expansion
Trendelenburg position Place the head of the bed lower than the feet. This position is used in situations such as hypotension and medical emergencies. It helps promote venous return to major organs such as the head and heart.
Trendelenberg position
Trendelenburg position
Data sources: Perry et al., 2018; Potter et al., 2017

Moving a Patient Up in Bed

When moving a patient in bed, perform a patient risk assessment prior to the procedure to determine the level of assistance needed for optimal patient care. If a patient is unable to assist with repositioning in bed, follow agency policy regarding “no patient lifts” and the use of mechanical lifts for complex and bariatric patients. See Checklist 27 for the steps to move a patient up in bed.

Checklist 27: Moving a Patient Up in Bed

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.
  • Ensure patient has a draw sheet and friction-reducing sheet on the bed prior to repositioning.

Steps

 Additional Information

1. Make sure an additional healthcare provider is available to help with the move.

This procedure requires two healthcare providers.

2. Explain to the patient what will happen and how the patient can help.

Doing this provides the patient with an opportunity to ask questions and help with the positioning.

3. Complete risk assessment (Checklist 24) of patient’s ability to help with the positioning.

This step prevents injury to patient and healthcare provider.

4. Raise bed to safe working height. The bed should be flat. Ensure brakes are applied. Healthcare providers stand on each side of the bed.

Principles of proper body mechanics help prevent MSI.

Safe working height is at waist level of the shortest healthcare provider.

Leaving the head of bed elevated increases effort required and increases risk of MSI.

Bed at waist level
Bed at waist level

5. Lay patient supine; place pillow at the head of the bed and against the headboard.

This step protects the head from accidentally hitting the headboard during repositioning.

6. Stand between shoulders and hips of patient with feet shoulder width apart. Weight will be shifted from back foot to front foot.

This keeps the heaviest part of the patient closest to the centre of gravity of the healthcare providers.
Feet shoulder width apart
Feet shoulder width apart

7. Fan-fold the draw sheet toward the patient with palms facing up.

This provides a strong grip to move the patient up using the draw sheet.
Fold sheet with fingers upwards
Fold sheet with fingers facing upward

8. Ask patient to tilt head toward chest, fold arms across chest, and bend knees to assist with the movement. Let the patient know when the move will happen.

This step prevents injury from patient and prepares patient for the move.
Chin tucked in and arms across chest
Chin tucked-in and arms across chest

9. Tighten your gluteal and abdominal muscles, bend your knees, and keep back straight and neutral.

The principles of proper body mechanics help prevent injury.

10. On the count of three by the lead person, gently slide (not lift) the patient up the bed, shifting your weight from the back foot to the front, keeping back straight with knees slightly bent.

The principles of proper body mechanics help prevent injury.

Facing direction of movement
Facing direction of movement

11. Replace pillow under head, position patient in bed, and cover with sheets.

This step promotes comfort and prevents harm to patient.

12. Lower bed, raise side rails as required, and ensure call bell is within reach. Perform hand hygiene.

Placing bed and side rails in safe positions reduces the likelihood of injury to patient. Proper placement of call bell facilitates patient’s ability to ask for assistance.
Bed in lowest position, side rail up, call bell within reach
Bed in lowest position, side rail up, call bell within reach

Hand hygiene reduces the spread of microorganisms.

Data sources: Perry et al., 2018; PHSA, 2010

Now complete the following online courses to learn more about how to move a patient up in bed.

Take the following PHSA courses:

Repositioning a Patient in Bed, Caregivers at Head teaches how to move a patient up in bed with caregivers at the head of the bed.

Repositioning a Patient in Bed, Caregivers Facing Each Other covers how to move a patient up in bed with the caregivers facing each other.

Repositioning a Patient in Bed, Diagonal Technique shows how to move a patient up in bed with the caregivers standing positioned diagonally.

Positioning a Patient to the Side of the Bed

Prior to ambulating, re-positioning, or transferring a patient from one surface to another (e.g., a stretcher to a bed), it may be necessary to move the patient to the side of the bed to avoid straining or excessive reaching by the healthcare provider. Positioning the patient to the side of the bed also allows the healthcare provider to have the patient as close as possible to the healthcare provider’s centre of gravity for optimal balance during patient handling. Checklist 28 describes how to safely move a patient to the side of the bed.

Checklist 28: Positioning a Patient to the Side of the Bed

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.
  • Ensure patient has a draw sheet and a friction-reducing sheet on the bed prior to repositioning.

Steps

 Additional Information

1. Make sure you have as many additional healthcare providers as needed to help with the move.

The procedure works best with two or more healthcare providers, depending on the size of the patient and the size of the healthcare professionals.

2. Explain to the patient what will happen and how the patient can help.

This provides the patient with an opportunity to ask questions and help with the positioning.

3. Raise bed to safe working height and ensure that brakes are applied. Lay patient supine.

Principles of proper body mechanics help prevent MSI.

Safe working height is at waist level of the shortest healthcare provider.

4. Stand on the side of the bed the patient is moving toward.

One person stands at the shoulder area and the other person stands near the hip area, with feet shoulder width apart.

This step keeps the heaviest part of the patient closest to the centre of gravity of the healthcare providers.
Keep heaviest part of the patient closest to your center of gravity
Keep heaviest part of the patient closest to your centre of gravity

5. Fan-fold the draw sheet toward the patient with palms facing up.

Fold sheet with fingers upwards
Fold sheet with fingers facing upward

6. Have the healthcare provider at the head of the bed grasp the pillow with one hand and the draw sheet with the other hand.

This prevents injury to patient.
Oct 2, 2015 035
Grasp the pillow with one hand and the draw sheet with the other

7. Have patient place arms across chest.

This step prevents injury to patient.
Chin tucked in and arms across chest
Chin tucked-in and arms across chest

8. Tighten your gluteal and abdominal muscles, bend your knees, and keep back straight and neutral. Place one foot in front of the other. The weight will shift from the front foot to the back during the move.

Use of proper body mechanics helps prevent injury when handling patients.

 

9. On the count of three by the lead person, with arms tight and shoulders down, shift your weight from the front foot to the back foot. Use your large leg muscles to move the patient. Do not lift, but gently slide the patient.

Weight on front leg
Start move with weight on front foot
Shift weight to back foot
Shift weight to back foot

If the patient is bariatric, the move should be repeated to correctly position the patient, or use a mechanical lift.

10. Once patient is positioned toward the side of the bed, ensure pillow is comfortable under the head, and straighten sheets. Complete all other procedures related to safe patient handling.

This step promotes comfort and prevents harm to patient.
Raise side rails
Raise side rails

11. Lower bed, raise side rails as required, and ensure call bell is within reach. Perform hand hygiene.

Placing bed and side rails in safe positions reduces the likelihood of injury to patient. Proper placement of call bell facilitates patient’s ability to ask for assistance.
Bed in lowest position, side rail up, call bell within reach
Bed in lowest position, side rail up, call bell within reach

Hand hygiene reduces the spread of microorganisms.

Data sources: Perry et al., 2018; PHSA, 2010
Take this PHSA Repositioning a Patient to One Side of the Bed course to learn how to position a patient to one side of the bed.

Critical Thinking Exercises

  1. Your patient is experiencing shortness of breath related to heart failure. Which position in bed might best help people with this condition?
  2. Consider how a mechanical assistive device might help with re-positioning a patient in bed.

Attribution

Figure 3.7 Tripod position by author is licensed under a Creative Commons Attribution 4.0 International License.

32

3.10 Assisting a Patient to Ambulate Using Assistive Devices

Immobility in hospitalized patients is known to cause functional decline and complications affecting the respiratory, cardiovascular, gastrointestinal, integumentary, musculoskeletal, and renal systems (Kalisch, Lee, & Dabney, 2013). For surgical patients, early ambulation is the most significant factor in preventing complications (Sanguinetti, Wild, & Fain, 2014). Lack of mobility and ambulation can be especially devastating to the older adult when the aging process causes a more rapid decline in function (Graf, 2006). Ambulation provides not only improved physical function, but also improves emotional and social well-being (Kalisch, Lee, & Dabney, 2013).

Prior to assisting a patient to ambulate, it is important to perform a patient risk assessment to determine how much assistance will be required. An assessment can evaluate a patient’s muscle strength, activity tolerance, and ability to move, as well as the need to use assistive devices or find additional help. The amount of assistance will depend on the patient’s condition, length of stay and procedure, and any previous mobility restrictions.

Before ambulating, the patient may need assistance getting to a sitting position.

Assisting Patient to the Sitting Position

Patients who have been immobile for a long period of time may experience vertigo, a sensation of dizziness, and orthostatic hypotension, a form of low blood pressure that occurs when changing position from lying down to sitting, making the patient feel dizzy, faint, or lightheaded (Potter et al., 2017). For this reason, always begin the ambulation process by sitting the patient on the side of the bed for a few minutes with legs dangling. Checklist 29 outlines the steps to positioning the patient on the side of a bed prior to ambulation (Perry et al., 2018).

Checklist 29: Assisting a Patient to a Sitting Position

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.
  • Follow the principles of proper body mechanics with all patient-handling procedures

Steps

Additional Information

1. Check prescriber’s orders for any restrictions related to ambulation due to medical treatment or surgical procedure. Equipment (proper footwear, gait belt, or assistive devices) must be gathered prior to ambulation. Do not leave patient sitting on the side of the bed unsupervised, as this poses a safety risk.
2. Explain what will happen and let the patient know how they can help. This step provides the patient with an opportunity to ask questions and help with the positioning.
3. Lower bed and ensure brakes are applied. This prepares the work environment.
4. Stand facing the head of the bed at a 45-degree angle with your feet apart, with one foot in front of the other. Stand next to the waist of the patient. Proper positioning helps prevent back injuries and provides support and balance.
5. Have patient turn onto side, facing toward the caregiver. Assist patient to move close to the edge of the bed. Turning, rolling, and leverage requires less work than lifting. This step prepares the patient to be moved.

 

Positioning patient on the side of the bed
Positioning patient on the side of the bed
6. Place one hand behind patient’s shoulders, supporting the neck and vertebrae. This provides support for the patient.

If available, use the electric bed to elevate the patient’s torso to a sitting position.

7. On the count of three, instruct the patient to use their elbows to push up on the bed and then grasp the side rails, as you support the shoulders as the patient sits up. Shift weight from the front foot to the back foot. Do not allow the patient to place their arms around your shoulders. This action can lead to serious back injuries.
8. At the same time as you’re shifting your weight, gently grasp the patient’s outer thighs with your other hand and help the patient slide their feet off the bed to dangle or touch the floor. This step helps the patient sit up and move legs off the bed at the same time.
Assisting patient into a sitting position
Assisting patient into a sitting position

9. Bend your knees and keep back straight and neutral.

Use of proper body mechanics helps prevent injury when handling patients.

10. On the count of three, gently raise the patient to sitting position. Ask patient to push against bed with the arm closest to the bed, at the same time as you shift your weight from the front foot to the back foot.

This allows the patient to help with the process and prevents injury to the healthcare provider.
Assist into a sitting position
Assist into a sitting position

11. Assess patient for orthostatic hypotension or vertigo.

If patient is not dizzy or lightheaded, the patient is safe to ambulate.

If patient becomes dizzy or faint, lay patient back down on bed.

12. Continue with mobilization procedures as required.

Mobilization helps prevent complications and improves physical function in hospitalized patients.
Data sources: Interior Health, 2013; Perry et al., 2018; PHSA, 2010

Assisting a Patient to Ambulate

Ambulation is defined as moving a patient from one place to another (Potter et al., 2010). Once a patient is assessed as safe to ambulate, the nurse must determine if assistance from additional healthcare providers or assistive devices is required. The following checklists provide guidance in assisting to ambulate using a gait belt or transfer belt (see Checklist 30), walker (Checklist 31), crutches (Checklist 32), and a cane (Checklist 33). 

Checklist 30: Assisting to Ambulate Using a Gait Belt / Transfer Belt

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.
  • The gait belt should fit snug and not tight around the patient’s waist.

Steps

Additional Information

1. Ensure patient does not feel dizzy or lightheaded and is tolerating the upright position.

Instruct the patient to sit on the side of the bed first, prior to ambulation.

Ensure proper footwear is on patient, and let patient know how far you will be ambulating.

Check physician’s orders for any activity restrictions related to treatment or surgical procedures.

Proper footwear is non-slip or slip-resistant footwear. Socks are not considered proper footwear. Proper footwear is essential in preventing accidental falls.
Footwear
Footwear
2. Explain to the patient what will happen and what they can do to  help.

Apply gait belt snugly around the patient’s waist.

Assessment and instructions prior to ambulation
Assessment and instructions prior to ambulation
Apply gait belt over clothing
Gait belts are applied over clothing.
Sept 22, 2015 121-001
Gait belt should be snug, not tight
3. Stand in front of the patient, grasping each side of the gait belt, keeping back straight and knees bent. The patient must be cooperative and predictable, able to bear weight on own legs, and have good trunk control.
4. While holding the belt, gently rock back and forth three times. On the third time, assist the patient to rise into a standing position. This action provides momentum to help patient into a standing position. Count out loud so the patient knows what to expect.
Rock back and forth to provide momentum
Rock back and forth to provide momentum
Pulled to a standing position
Pulled to a standing position
5. Once patient is standing and feels stable, move to the unaffected side and grasp the gait belt in the middle of the back. With the other hand, hold the patient’s hand closest to you. Standing to the side of the patient provides assistance without blocking the patient.
6. Before ambulating ask the patient if they feel dizzy or lightheaded. If they do, sit patient back down on the bed.

If patient feels stable, begin walking, matching your steps to the patient’s. Instruct patient to look ahead and lift each foot off the ground.

Risk assessment is ongoing.

Walk only as far as the patient can tolerate without feeling dizzy or weak.

 

7. To help a patient back to bed, have patient stand with back of knees touching the bed. Grasp the gait belt and help patient into a sitting position, keeping your back straight and knees bent. Allowing a patient to rest after ambulation helps prevent fatigue.

Short frequent walks help to build stamina.

8. When patient is finished ambulating, remove gait belt, and settle patient into bed or a chair. This provides a safe place for the patient to rest.
Apply gait belt over clothing
Remove gait belt
9. Leave the patient in a safe place. If in bed, place the bed in lowest position, raise side rails as required, and ensure call bell is within reach. Perform hand hygiene. Placing bed and side rails in a safe position reduces the likelihood of injury to patient. Proper placement of call bell facilitates patient’s ability to ask for assistance.
Bed in the lowest position, call bell in reach, and side rail up
Bed in the lowest position, call bell in reach, and side rail up

Hand hygiene reduces the spread of microorganisms.

10. Document patient’s ability to tolerate ambulation and type of assistance required. Update the care plan as required. This provides a baseline of patient’s abilities and promotes clear communication between health care providers.
Data sources: Interior Health, 2013; Perry et al., 2018; PHSA, 2010
Watch the video How to Ambulate With or Without a Gait Belt or Transfer Belt (2018) by Kim Morris of Thompson Rivers University School of Nursing.

Checklist 31: Ambulating with a Walker

Figure 3.8 Walking with a walker
Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure proper fitting footwear is used.
  • Use rubber tips to prevent the device from slipping.
  • Avoid scatter rugs.
  • Inspect rubber ends after being outside and remove any gravel.

Steps

Additional Information

1. Ensure proper footwear is on the patient, and let the patient know how far you will be ambulating. Proper footwear is non-slip or slip-resistant footwear. If in acute care, check prescriber’s orders for any activity restrictions related to treatment or surgical procedures. Proper footwear is essential to prevent accidental falls.
Footwear
Footwear
2. Measure client for walker height.
Figure 3.9 Standing with the support of a walker

The top of the walker should line up with the crease on the inside of the wrists when one is standing. Elbows should flex 15-30 degrees when standing inside the walker with hands on the hand grips.

3. Explain and demonstrate how to walk with a walker.
Assessment and instructions prior to ambulation
Assessment and instructions prior to ambulation
4. From a sitting position, instruct patient to push up from the chair’s armrest to a standing  position. Do not use the walker to pull oneself up. It is not stable and could result in injury.
Figure 3.10 Preparing to move from a chair to using a walker

Apply gait belt if required for additional support.

5. Firmly grip both sides of the walker.

Move the walker forward a short distance.

The base of the walker provides a broad base of support.

Once patient is standing and feels stable, move to the unaffected side. If using a gait belt, grasp the belt in the middle of the patient’s back.

6. Step forward with the injured or weak leg first, taking weight through one’s hands.

Then step with the stronger leg.

Do not step forward if all four feet of the walker are not in contact with the floor.

Walker – weak leg – strong leg.

Keep feet within the walker’s boundaries.

Advise the patient to look forward not down at the floor.

7. To turn: Advise to take small steps, moving the walker and then the legs. Avoid twisting the knee joint when turning. Walking in a large circle may be necessary.
Data sources: Cleveland Clinic, 2018a; Perry et al., 2018

Checklist 32: Ambulating  with Crutches

Figure 3.11 Walking with forearm crutches
Figure 3.12 Walking with crutches (axilla height)
Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure proper fitting footwear is used.
  • Use rubber tips to prevent the device from slipping.
  • Avoid scatter rugs.
  • Inspect rubber ends after being outside, and remove any gravel.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.

Steps

Additional Information

1. Ensure proper footwear is on the patient, and let the patient know how far you will be ambulating. Proper footwear is non-slip or slip-resistant footwear. If in acute care, check prescriber’s orders for any activity restrictions related to treatment or surgical procedures.  Proper footwear is essential to prevent accidental falls. An informed patient is part of delivering safe patient care.
Footwear
Footwear
 2. Ensure crutch height is correct. Axilla height crutches: When standing, the there should be two to three finger widths from the axilla to the top of the crutch. The height of the hand grip will be adjusted to allow the elbow to be flexed 15 to 30 degrees or to the wrist crease. There are different crutch walking techniques that depend on the patient’s ability to bear weight.

Forearm crutches: The elbows should be flexed 15 to 30 degrees when holding the hand grips. The forearms should be supported roughly mid-point between the wrist and elbow.

 3. Explain and demonstrate how to walk with crutches.  An informed patient may result in reduced risk of falls.
4. From a sitting position, advise the patient to push up from the chair’s armrest to a standing  position. Stand to gain balance. Advise the patient to not lean on the underarm supports. The patient should be cooperative and predictable, able to bear weight on own legs, and to have good trunk control. Apply gait belt if required for additional support.

Pressure on the axilla can cause damage to tissues and nerves.

5 a. Advise patient accordingly:

Ambulation method #1:

  • Establish balance.
  • Move both crutches forward slightly.
  • Move injured leg forward.
  • Push down on the crutch hand grips.
  • Step through the crutches with the good leg.
  • Ensure balance is maintained.
  • Repeat.
Bear in mind any weight bearing limitations.
5 b. Ambulation method #2:
  • Establish balance.
  • Move the crutches and the injured leg forward simultaneously.
  • Push down on the crutch hand grips.
  • Step through the crutches with the good leg.
  • Ensure balance is maintained.
  • Repeat.
Ambulation method #2 requires good balance and trunk strength.
6 a. Ascending stairs:
  • Stand close to and facing the bottom step.
  • Step up with the strong leg.
  • Ensure balance is maintained.
  • Move the weak / injured leg onto the step.
  • Move the crutches up.
  • Repeat.
Strong leg – weak leg – crutches.

Use of the hand rail may be helpful.

6 b. Descending stairs:
  • Stand close to the top step and face the stairs.
  • Move crutches to the next step down keeping weight on the hand grips.
  • Step down with weak / injured leg.
  • Ensure balance is maintained.
  • Step down with good / strong leg.
  • Repeat.
Crutches – weak leg – strong leg.

Use of the hand rail may be helpful.

Data sources: Cleveland Clinic, 2018b; Perry et al., 2018
Watch the video How to Ambulate With Crutches (2018) by Kim Morris of Thompson Rivers University School of Nursing.

Checklist 33: Ambulating with a Cane

Figure 3.13 Different types of canes
Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Complete risk assessment for safer patient handling 
  •  Complete QPA including safety.
  • Ensure proper fitting footwear is used.
  • Use rubber tips to prevent the device from slipping.
  • Avoid scatter rugs.
  • Inspect rubber ends after being outside, and remove any gravel.
  • Ensure tubes and attachments are properly placed prior to the procedure to prevent accidental removal.

Steps

Additional Information

  1. Let patient know how far you plan to ambulate. 

Proper footwear is non-slip or slip-resistant footwear. 

 

 Proper footwear is essential to prevent accidental falls. An informed patient is part of delivering safe patient care.
Footwear
Footwear
 2. Ensure cane height is correct. Cane height is the length from the greater trochanter to the floor. Allow 15 to 30 degree flexion at the elbow.
 3. Explain and demonstrate how to walk with crutches.  An informed patient may result in reduced risk of falls.
4. Encourage the patient to get to a standing position. Quad cane: Push up from the armrest of the chair to standing position. Grasp cane and establish balance.
Figure 3.14 Cane height – from floor to greater trochanter. Elbow bent slightly

Standard cane: Hold the cane handle in one hand. Push up from the armrest to standing position. Establish balance.

5. Advise the patient to move the cane forward a short distance. Cane position is forward and slightly to the side when ambulating.
6. Step forward with injured / weak leg. Put weight onto the cane handle. Then step with the strong leg. Cane – weak leg – strong leg.
7 a. Ascending stairs:
  • Stand close to and facing the bottom step.
  • Step up with the strong leg.
  • Ensure balance is maintained.
  • Step up with the injured / weak leg.
  • Bring cane up.
  • Repeat.
Strong leg – weak leg – cane.

Quad canes may have to be turned sideways to fit on a stair.

Use of hand rail may help improve balance.

7 b. Descending stairs:
  • Stand close to the top step and face the stairs.
  • Place cane down onto the next step.
  • Step down with weak / injured leg.
  • Ensure balance is maintained.
  • Step down with good / strong leg.
  • Repeat.
Data sources: Cleveland Clinic, 2018c; Perry et al., 2018
Watch the video How to Ambulate with a Cane (2018) by Kim Morris of Thompson Rivers University School of Nursing. 

Critical Thinking Exercises

  1. A 90-year-old patient is required to ambulate. He had a total hip arthroplasty and is post-operative day 2 (POD 3). What risk factors should be considered prior to ambulating an elderly patient who has been immobile after hip surgery?
  2. Does ambulation require an order from a prescriber?
  3. What should you do if a patient feels dizzy or lightheaded before ambulation?

Attributions

Figure 3.8 Walker by rawpixel.com is free of copyright.

Figure 3.9 Standing with support of a walker by author is licensed under a Creative Commons Attribution 4.0 International License.

Figure 3.10 Preparing to move from chair to walker by author  is licensed under a Creative Commons Attribution 4.0 International License.

Figure 3.11 Teenage boy on crutches with walking boot by Pagemaker787 is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 3.12 An illustration depicting walking on crutches by BruceBlaus is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 3.13 An illustration depicting different cane types by BruceBlaus is used under a Creative Commons Attribution-Share Alike 4.0 International license.

Figure 3.14 Cane height by author  is licensed under a Creative Commons Attribution 4.0 International License.

33

3.11 Fall Prevention

Patient falls are the most reported patient safety events in British Columbia and account for 40% of all adverse events (BCPSLS Central, 2015). Falls are a major priority in healthcare, and healthcare providers are responsible for identifying, managing, and eliminating potential hazards to patients. Older adults may be at increased risk for falls due to impaired mental status, decreased strength, impaired balance and mobility, and decreased sensory perception (Titler et al., 2011). Other patients may be at risk due to gait problems, cognitive ability, visual problems, urinary frequency, generalized weakness, and cognitive dysfunction. Specific treatments and medications may cause hypotension or drowsiness, which increases a patient’s risk for falls (Hook & Winchel, 2006).

Fall Prevention Strategies

All clients should be assessed for risk factors, and necessary prevention measures should be implemented as per agency policy. Table 3.8 lists factors that affect patient safety and general measures to prevent falls in healthcare.

Table 3.8 Fall Prevention Strategies

Prior to ambulation consider the following risk factors:
  • Age (elderly)
  • Sensory-perception alteration
  • Cognitive impairment (decreased LOC, confusion)
  • Poly-pharmacology
  • Urinary incontinence
  • Ability to communicate (language barriers)
  • Lack of safety awareness (height of bed, attachments and tubes)
  • Environmental factors (dim light, tripping hazards, uneven floors)

Prevention Strategies

Safety Measures

Look for fall risk factors in all patients. Identifying specific factors helps you implement specific preventive measures. Risk factors include age, weakness on one side, the use of a cane or walker, history of dizziness or lightheadedness, low blood pressure, and weakness.
Follow hospital guidelines for transfers. Transfer guidelines provide a good baseline for further patient risk assessments.
Orient patient to surroundings. Orient patients to bed, surroundings, location of bathroom and call bell, and tripping hazards in the surrounding environment.
Answer call bells promptly. Long wait times may encourage unstable patients to ambulate independently.
Ensure basic elimination and personal needs are met. Provide opportunities for patients to use the bathroom and to ask for water, pain medication, or a blanket.
Ensure patient has proper footwear and mobility aids. Proper footwear prevents slips.
Proper Footwear
Proper footwear
Communicate with your patients. Let patients know when you will be back, and how you will help them ambulate.
Keep bed in the lowest position for sedated, unconscious, or compromised patients. This step prevents injury to patients should they attempt to get out of bed.
Avoid using side rails when a patient is confused. Side rails may create a barrier that can be easily climbed and create a fall risk situation for confused patients.
Keep assistive devices and other commonly used items close by. Allow patients to access assistive devices quickly and safely. Items such as the call bell, water, and Kleenex should be kept close by, to avoid any excessive reaching.
Data sources: Canadian Patient Safety Institute, 2015; Perry et al., 2018; Titler et al., 2011

Lowering a Patient to the Floor

A patient may fall while ambulating or being transferred from one surface to another. If a patient begins to fall from a standing position, do not attempt to stop the fall or catch the patient. Instead, control the fall by lowering the patient to the floor. Checklist 34 lists the steps to assisting a patient to the floor to minimize injury to patient and healthcare provider (PHSA, 2010).

Checklist 34: Lowering a Patient to the Floor

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • There is always a potential fall risk during transfers and ambulation. Prevention is key.
  • If a patient begins to feel dizzy, have them sit on a chair or the floor to avoid a fall.
  • The head is the most important part of the body; always protect it as much as possible.
  • In the event of a fall, stay with the patient until help arrives.
  • After a fall, always assess a patient for injuries prior to moving them. If the patient remains weak or dizzy, do not attempt to ambulate them. Seek help.
  • Document according to agency policy including the PSLS (patient safety learning system).

Steps

 Additional Information

1. If a patient starts to fall and you are close by, move behind the patient and take one step back. Look and be attentive to cues if a patient is feeling dizzy or weak.
Stand behind patient
Stand behind patient
2. Support the patient around the waist or hip area, or grab the gait belt. Bend your leg and place it in between the patient’s legs. Hand placement allows for a solid grip on the patient to guide the fall.
Support patient by grabbing the hips area or gait belt
Support patient by grabbing the hip area or gait belt
3. Slowly slide the patient down your leg, lowering yourself at the same time. Always protect the head first. Lowering yourself with the patient prevents back injury and allows you to protect the patient’s head from hitting the floor or hard objects.
Lower patient to the floor
Lower patient to the floor
4. Once the patient is on the floor, assess the patient for injuries prior to moving. Assesses patient’s ability, or need for additional help, to get off the floor.
Support the patient's hip area or grab hold of the gait belt
Assess patient prior to moving
5. Provide reassurance and seek assistance if required. If required, stay with the patient and call out for help.
6. If patient is unable to get up off the floor, use a mechanical lift. If patient still feels dizzy or weak, using a mechanical lift will prevent injury.
7. Complete an incident report according to agency policy. An incident report helps identify and manage risks related to patient falls.
Data sources: Perry et al., 2018; PHSA, 2010; Titler et al., 2011
Special considerations:
Take PHSA’s Lowering a Patient to the Floor course for more information on lowering a falling patient to the floor.
Watch the video Assisted Fall (2018) by Kim Morris of Thompson Rivers University School of Nursing.

Critical Thinking Exercises

  1.  Name four fall prevention strategies that will help keep a patient safe when ambulating in the hospital.
  2. A patient is ambulating for the first time after surgery. Is it safe to encourage the patient to ambulate independently?
  3. Many physiological risk factors can be identified from a routine assessment to suggest risk for falls. Name three risk factors and three prevention strategies to manage these risks. For example, if a patient has frequent toileting needs, a preventive action is to offer assistance to the toilet every hour, and to ensure the call bell is within reach at all times.

34

3.12 Summary

To use the principles of body mechanics effectively and safely, healthcare providers must have the required training to perform a risk assessment, knowledge about transfer assistive devices, and an understanding of the procedures for safe patient handling. In addition, knowing risk factors for positioning, transferring, and ambulation, along with understanding falls prevention, will help prevent injuries to staff and patients. The goal of this chapter has been to help reduce the incidence and severity of injuries related to patient-handling procedures.

Key Takeaways

  • Patients’ conditions and their ability to move will change over the course of their hospital stay. A patient risk assessment must be done prior to all patient-handling procedures.
  • MSI can result from any type of handling procedure. The principles of proper body mechanics can be applied to all procedures related to positioning, transferring, and ambulation. Correct posture and keeping the patient close to your centre of gravity are essential to maintain balance during transfers, positioning, and ambulation.
  • Educate yourself on standard procedures to protect yourself from injury. Retrain and keep current with new procedures and assistive devices.
  • The use of assistive devices can help a patient transfer safely and effectively.
  • Always seek additional assistance and help as required.
  • Keep yourself healthy with exercise and a proper diet, along with suitable footwear, to help prevent injury. If a MSI is suspected, seek help immediately and report the incident.
  • Avoid trying to catch a falling patient. If possible, follow the guidelines to lower a falling patient to the floor.
  • Be proactive to implement safe strategies and prevent hazards in the workplace related to patient handling.

Suggested Online Resources

  1. Agency for Healthcare Research and Quality: Which Fall Prevention Practices Do You Want to Use? (2013). These universal fall risk precautions review physiological, anticipated, unanticipated, and environmental hazards with a focus on identifying risk factors and prevention strategies.
  2. BC Interior Health: Safe Patient Handling (n.d.). This website lists excellent resources, including brochures and videos, about topics related to body mechanics, transfers, positions, and performing risk assessments.
  3. BC Patient Safety & Quality Council: Hospital Care for Seniors: 48/6 Approach (2012). This resource offers a model of care for hospitalized seniors (aged 70 and older) in British Columbia. It is an integrated care initiative that addresses six care areas of functioning through patient screening and assessment (assessments are completed only where screening shows areas of concern) within the first 48 hours of hospital admission.
  4. Canadian Fall Prevention Education Collaborative: Canadian Fall Prevention Curriculum (2017). This website provides information and tool kits for preventing falls in the community and acute care settings.
  5. Centers for Disease Control and Prevention: Safe Patient Handling Training for Schools of Nursing (2009). This resource was developed by the World Health Organization to create global awareness. It provides up-to-date algorithms for patient transfers.
  6. Provincial Health Services Authority: Safe Patient Handling (2010). These instructional video courses cover numerous topics including mechanical (ceiling) lifts, additional re-positioning techniques, transfers, and assisting a patient off the floor.

References

Berman, A., & Snyder, S. J. (2016). Skills in clinical nursing (8th ed.). Hoboken, NJ: Pearson.

British Columbia Patient Safety Learning System (BCPSLS) Central. (2015). Retrieved from http://bcpslscentral.ca/.

Canadian Patient Safety Institute. (2015). Reducing falls and injury from falls: Getting started kit. Retrieved from http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Getting%20Started%20Kit.pdf.

Cleveland Clinic. (2018a). Walkers. Retrieved from https://my.clevelandclinic.org/health/articles/15542-walkers.

Cleveland Clinic. (2018b). Crutches.  Retrieved from https://my.clevelandclinic.org/health/articles/15543-crutches.

Cleveland Cinic. (2018c). Canes. Retrieved from https://my.clevelandclinic.org/health/articles/15541-canes.

Graf, C. (2006). Functional decline in hospitalized older adults. It’s often a consequence of hospitalization, but it doesn’t have to be. American Journal of Nursing, 101(1), 58-67. Retrieved from http://www.researchgate.net/publication/232182376_Functional_Decline_in_Hospitalized_Older_Adults_Its_often_a_consequence_of_hospitalization_but_it_doesnt_have_to_be.

Handicare. (2018). How to choose the proper sling. Retrieved  https://www.handicare.ca/blog/2018/08/24/how-to-choose-the-proper-sling/

Hook, M. L., & Winchel, S. (2006). Fall related injuries in acute care: Reducing the risk of harm. Clinical Practice, 15(6), 370-377.

HoverTech International. (2016). HoverMatt air transfer system. Retrieved from  http://www.hovermatt.com/hovermatt.html.

Interior Health. (2012). Point-of-care risk assessment. Retrieved from https://www.interiorhealth.ca/sites/Partners/WHSresources/Documents/Point%20of%20Care%20Risk%20Assessment%20Tool.pdf.

Interior Health. (2013). Manual transfer: One person assist with help. Retrieved from https://www.interiorhealth.ca/sites/Partners/WHSresources/Documents/Manual%20Transfers%20-%20One%20Person%20Assist%20with%20Help%20SWP.pdf.

Kalisch, B. J., Lee, S., & Dabney, B. W. (2013). Outcomes of inpatient mobilization: A literature review. Journal of Clinical Nursing, 23(11-12), 1486-501. https://doi.org/10.1111/jocn.12315

National Institute for Occupational Safety and Health (NIOSH). (2010). Safe patient handling training for schools of nursing. Retrieved from http://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf.

Peninsula Health. (1999). Falls risk assessment tool (FRAT). Retrieved from https://www2.health.vic.gov.au/about/publications/policiesandguidelines/falls-risk-assessment-tool.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing skills and techniques (9th ed.). St. Louis, MO: Elsevier-Mosby.

Potter, P. A., Perry, A. G., Stockert, P., Hall, A., Astle, B., & Duggleby, W. (2017). Canadian fundamentals of nursing (6th ed.). Milton, ON: Mosby.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2011). Basic nursing (7th ed.). St. Louis, MO: Elsevier-Mosby.

Provincial Health Services Authority (PHSA). (2010). Workplace health – Safe patient handling [Online courses]. Retrieved from http://learn.phsa.ca/phsa/patienthandling/.

Registered Nursing. (n.d.). Ergonomic principles: NCLEX-RN. Retrieved from https://www.registerednursing.org/nclex/ergonomic-principles/.

Sanguineti, V. A., Wild, J. R., & Fain, M. J. (2014). Management of postoperative complications: A general approach. Clinics in Geriatric Medicine, 30(2), 261-270. https://doi.org/10.1016/j.cger.2014.01.005.

South Island Alliance. (n.d.). Level of assistance definitions. Retrieved from https://www.sialliance.health.nz/UserFiles/SouthIslandAlliance/File/LEVEL%20OF%20ASSISTANCE%20DEFINITIONS%202016.pdf.

Stewart, D. (2018). Ceiling lift sling information. Retrieved from https://mobilitybasics.ca/ceiling-lifts/slings.

Titler, M. G., Shever, L. L., Kanak, M. F., Picone, D. M., & Qin, R. (2011). Factors associated with falls during hospitalization in an older adult population. Research and Theory for Nursing Practice: An International Journal, 25(2), 127-152. https://doi.org/10.1891/1541-6577.25.2.127.

Winnipeg Regional Health Authority (WRHA). (2015). Safe patient handling assessment form. Retrieved from http://www.wrha.mb.ca/professionals/safety/files/SafePatientHandling/SafePatientHandlingAssessmentForm.pdf.

Winnipeg Regional Health Authority (WRHA). (2008). Patient assessment procedures and screening tool. Retrieved from http://www.wrha.mb.ca/professionals/safety/files/SafePatientHandling/PatientAssessmentProcedure.pdf.

WorkSafeBC. (2006). Handle with care: Patient handling and the application of ergonomics (MSI) requirements. Retrieved from https://www.worksafebc.com/en/resources/health-safety/books-guides/handle-with-care-patient-handling-application-ergonomics-musculoskeletal-msi-requirements?lang=en&origin=s&returnurl=https%3A%2F%2Fwww.worksafebc.com%2Fen%2Fsearch%23q%3Dtransfer%2520assist%2520devices%2520for%2520safer%26sort%3Drelevancy%26f%3Alanguage-facet%3D%5BEnglish%5D.

WorkSafeBC. (2008). Understanding the risks of musculoskeletal injury (MSI): An educational guide for workers on sprains, strains, and other MSIs. Retrieved from http://www.worksafebc.com/publications/Health_and_Safety/by_topic/assets/pdf/msi_workers.pdf.

WorkSafeBC. (2010). Patient handling. Retrieved from https://www.worksafebc.com/en/health-safety/industries/health-care-social-services/topics/patient-handling.

WorkSafeBC. (2013). Preventing musculoskeletal injury (MSI). Retrieved from http://www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/msi_employers.pdf.

World Health Organization. (2018). Assistive devices and technology. Retrieved from https://www.who.int/disabilities/technology/en/.

IV

Chapter 4. Wound Care

35

4.1 Introduction

Wound healing is a complex physiological process. It occurs after an injury in the cells and tissues of our bodies to restore function of the tissue. The healing process is affected by the severity of the wound, location, extent of injury, and other external and internal factors that will either inhibit or promote wound healing. A health care provider must understand how to assess a wound, assess external and internal factors, and determine treatment to optimize the healing process.

Learning Outcomes

  • Describe six factors that affect wound healing, and possible strategies that the nurse can implement to promote wound healing.
  • Describe four stages of (uncomplicated) wound healing.
  • Describe 2  individual, 2 environmental and 2 wound factors that contribute to risk of infection and possible strategies that the nurse can implement to decrease that risk
  • Perform a comprehensive wound assessment.
  • Differentiate situations that require sterile versus clean technique when performing dressing changes.
  • Perform the following skills following principles of asepsis:
    • Simple dressing change
    • Wound irrigation
    • Wound packing
    • Staple removal
    • Suture removal
    • Empty and remove JP and hemovac drains

36

4.2 Wound Healing and Assessment

Wound healing is a dynamic process of restoring the anatomic function of living tissue. Since damage to the body’s tissue is common, the body is well adapted to utilizing mechanisms of repair and defence to elicit the healing process. Normal wound healing is profoundly influenced by the type of injury and by factors about the wound (intrinsic) and within the patient (extrinsic) (Perry et al., 2014).

Phases of Wound Healing

There are four distinct phases of wound healing. These four phases must occur in correct sequence and in a correct time frame to allow the layers of the skin to heal (see Figure 4.1).

Table 4.1 describes how a wound heals.

Table 4.1 Phases of Wound Healing for Full Thickness Wounds

Phase

 Additional Information

Hemostasis phase Blood vessels constrict and clotting factors are activated. Clot formation blocks the bleeding and acts as a barrier to prevent bacterial contamination. Platelets release growth factors, which alert various cells to start the repair process at the wound location.
Inflammatory phase Vasodilation occurs, allowing plasma and leukocytes (white blood cells) into the wound to start cleaning the wound bed. This process is seen as edema, erythema, and exudate. Macrophages (another type of white blood cell) work to regulate the cleanup.
Proliferative phase Four important processes occur in this phase:
  1. Epithelialization: New epidermis and granulation tissue are developed.
  2. New capillaries: angiogenesis occurs to bring oxygen and nutrients to the wound.
  3. Collagen formation: This provides strength and integrity to the wound.
  4. Contraction: The wound begins to reduce in size.
Maturation (remodelling) phase Collagen continues to strengthen the wound, and the wound becomes a scar.
Data sources: British Columbia Provincial Nursing Skin and Wound Committee, 2011; Perry et al., 2014

 

Phases of wound healing https://upload.wikimedia.org/wikipedia/commons/a/a6/Wound_healing_phases.svg
Figure 4.1 Phases of wound healing

Types of Wounds

To determine how to treat a wound, consider the etiology, amount of exudate, and available products to plan appropriate treatment. Wounds are classified as acute (healing occurs in a short time frame without complications) or chronic (healing occurs over weeks to years, and treatment is usually complex). Examples of acute wounds include a surgical incision or a traumatic wound (e.g., a gunshot wound). Examples of chronic wounds include venous and arterial ulcers, diabetic ulcers, and pressure ulcers. Table 4.2 lists the six main types of wounds.

Table 4.2 Types of Wounds

Type

Additional Information

Surgical Healing occurs by primary, secondary, or tertiary intention.

Primary intention is where the edges are sutured or stapled closed, and the wound heals quickly with minimal tissue loss. The healing time for a surgical wound is usually short, depending on the surgery.

A surgical wound left open to heal by scar formation is a wound healed by secondary intention. In this type of wound, there is a loss of skin, and granulation tissue fills the area left open. Healing is slow, which places the patient at risk for infection. Examples of wounds healing by secondary intention include severe lacerations or massive surgical interventions.

Healing by tertiary intention is the intentional delay in closing a wound. On occasion, wounds are left open (covered by a sterile dressing) to allow an infection or inflammation to subside. Once the wound is closed with staples or sutures, the scarring in minimal.

Traumatic Examples are gunshot wounds, stab wounds, or abrasions. These wounds may be acute or chronic.
Diabetic/neuropathic ulcer This is a nerve disorder that results in the loss or impaired function of the tissues affecting nerve fibres. These wounds generally occur as a result of damage to the autonomic, sensory, or motor nerves and have an arterial perfusion deficit. They are usually located in the lower extremity on the foot. Diabetic/neuropathic ulcers are often small with a calloused edge. Pain may be absent or severe depending on the neuropathy.
Arterial ulcer Arterial ulcers occur when tissue ischemia occurs due to arterial insufficiency from the narrowing of an artery by an obstruction (atherosclerosis). They are located on the distal aspects of the arterial circulation, and can be anywhere on the legs, including feet or toes, and sometimes the fingers and hands. Wound margins are well defined with a pale wound bed with little or no granulation. Necrotic tissue is often present. There is minimal to no exudate present. Peripheral pulses are usually absent or diminished. Pain occurs in limb at rest, at night, or when limb is elevated.

Arterial ulcers account for 5% to 20% of all leg ulcers. Perfusion must be assessed prior to initiating treatment.

Venous ulcer A venous ulcer is a lower extremity wound. Tissue ischemia occurs due to the failure of the venous valve function to return blood from the lower extremities to the heart. It is usually located in the ankle to mid-calf region, usually medial or lateral, and can be circumferential. Drainage can be moderate to heavy. A venous ulcer can be irregularly shaped, large, and shallow with generalized edema to lower limbs. Pulse may be difficult to palpate.

Venous ulcers account for 70% to 90% of all leg ulcers. Perfusion must be assessed prior to initiating treatment.

Pressure injury Also known as a pressure sore or decubiti wound, the pressure injury refers to a localized area of tissue damage that results from compression of soft tissue between a hard surface and a bony prominence (coccyx, ankle, shoulder blade, or hip). As blood supply decreases to the area of compression, tissue anoxia occurs, which can lead to eventual tissue death. Wounds are usually circular and may have viable or necrotic tissue, and exudate can vary from none to heavy. Pressure ulcers are classified depending on the level of tissue damage (stages 1 to 4). Treatment is based on stage, exudate, type of available dressing, and frequency of dressing changes.
Data sources: British Columbia Provincial Nursing Skin and Wound Committee, 2011, 2014; Perry et al., 2014

Wound Healing

Wounds require different treatment throughout the phases of healing. There are multiple factors that affect how a wound heals as it moves through the phases of healing. It is important to look at the “whole patient” rather than the “hole in the patient” to identify the correct treatment and work efficiently and effectively from the beginning of the healing process.

Table 4.3 lists a number of factors that inhibit the ability of tissues and cells to regenerate, which can delay healing and contribute to wound infections.

Table 4.3 Patient Considerations for Wound Healing

Influencing Factors

 Additional Information

Patient’s age Vascular changes occur with increasing age, skin is less pliable, and scar tissue is tighter.

For example, an older adult’s skin tears more easily from mechanical trauma such as tape removal.

Patient’s nutritional status Tissue repair and infection resistance are directly related to adequate nutrition.

Patients who are malnourished are at increased risk for wound infections and wound infection-related sepsis.

Patient’s size Inadequate vascularization due to obesity will decrease the delivery of nutrients and cellular elements required for healing.

An obese person is at greater risk for wound infection and dehiscence or evisceration.

Oxygenation Factors such as decreased hemoglobin level, smoking, and underlying cardiopulmonary conditions will decrease oxygenation.

Adequate oxygenation at the tissue level is essential for adequate tissue repair.

Hemoglobin level and oxygen release to tissues is reduced in smokers.

Patient’s medications Steroids reduce the inflammatory response and slow collagen synthesis.

Cortisone depresses fibroblast activity and capillary growth.

Chemotherapy depresses bone marrow production of white blood cells and impairs immune function.

Chronic diseases or trauma Chronic diseases and traumas such as diabetes mellitus or radiation decrease tissue perfusion and oxygen release to tissues. Chronic wounds may be colonized with microbes; wound beds may have reached a point of chronicity and require debridement to initiate the inflammatory process and (hopefully begin healing). Pressure, friction, and shear can contribute to the development of pressure injury.
Data source: Gallagher-Camden, 2012; Perry et al., 2014; Stotts, 2012
Watch this 30-minute video about How Wounds Heal from Connecting Learners with Knowledge (CLWK), a provincial resource and is licensed under a CC BY-NC-ND 2.5 Canada licence.

Wound Assessment

Frequent wound assessment based on the type, cause, and characteristics of the wound is necessary to help determine the type of treatment required to manage the wound effectively and to promote maximal healing. The health care professional should always compare the wound to the previous assessment to determine progress toward healing. If there has been no improvement in the healing of the wound, alternative options or consulting a wound care specialist should be considered.

Table 4.4  outlines considerations when assessing a wound.

 Table 4.4 : Wound Assessment

Considerations

 Additional Information

1. Location Note the anatomic position of the wound on the body.
2. Type of wound Note the etiology (cause) of the wound (i.e., surgical, pressure, trauma).

Common types are pressure, venous, arterial, or neuropathic/diabetic foot ulcers, or surgical or trauma wounds.

3. Extent of tissue involvement A full-thickness wound involves both the dermis and epidermis.

A partial-thickness wound involves only the epidermal layer.

If the wound is a pressure ulcer, use the Braden Scale Interventions Algorithm.

4. Type and percentage of tissue in wound base Describe the type of tissue (i.e., granulation, slough, eschar) and the approximate amount.
5. Wound size Follow agency policy to measure wound dimensions, including width, depth, and length.

Assess for a sinus tract, tunnelling, or induration.

6. Wound exudate Describe the amount, colour, and consistency:
  • Serous drainage (plasma): clear or light yellowish
  • Sanguineous drainage (fresh bleeding): bright red
  • Serosanguineous drainage (a mix of blood and serous fluid): pink
  • Purulent drainage (infected): thick and yellow, pale green, or white
7. Presence of odour Note the presence or absence of odour. The presence of odour may indicate infection.
8. Peri-wound area Assess the temperature, colour, and integrity of the skin surrounding the wound.
9. Pain Assess pain.
Data sources: British Columbia Provincial Nursing Skin and Wound Committee, 2014; Perry et al., 2014
Watch this 30-minute Wound Assessment video, a provincial resource from CLWK, to learn how to improve wound-assessment skills. It is licensed under a CC BY-NC-ND 2.5 Canada license.

Critical Thinking Exercises

  1. A patient is 75 years old, smokes cigarettes, has renal disease, and is overweight. What additional factors should you consider prior to assessing the patient’s wound? Provide rationale.
  2. What indications might lead the nurse to suspect that a patient is malnourished and therefore at risk for delayed wound healing?
  3. What phase of wound healing is indicated by the presence of epithelialization and wound contraction? Name three extrinsic factors that can contribute to the risk of pressure injury.

Attributions

Figure 4.1 Phases of wound healing by Mikael Häggström is in the public domain.

37

4.3 Wound Infection and Risk of Wound Infection

Wound Infection

Wounds are not sterile because normal flora is a part of human existence. Even intentional wounds contain microbes which may include bacteria and fungi. It is important for the nurse to recognize that presence of bacteria in a wound does not necessarily mean infection. It is also important for the nurse to recognize their role in reducing risk of infection through standard precautions and by working with the patient and interdisciplinary team to mitigate factors that might contribute to patient risk. The wound infection continuum is characterized by increasing numbers and virulence of microorganisms and the host’s response to them.

Table 4.5 Wound Infection Continuum and S&S Associated with Each Stage

Contamination All wounds may acquire micro-organisms. If the ideal microbe environment does not exist and host defenses are strong, microbes cannot multiply. They are present but don’t affect wound healing.
Local Infection Subtle signs of local infection:
  • Hyper granulation (excessive “vascular” tissue)
  • Bleeding, friable granulation
  • Epithelial bridging and pocketing in granulation tissue
  • Wound breakdown and enlargement
  • Delayed wound healing beyond expectations
  • New or increasing pain
  • Increasing malodor
Classic signs of local infection:
  • Erythema
  • Local warmth
  • Swelling
  • Purulent discharge
  • Delayed wound healing beyond expectations
  • New or increasing pain
  • Increasing malodor
Spreading Infection
  • Extending in duration
  • +/- erythema Lymphangitis Crepitus
  • Wound breakdown/dehiscence with or without satellite lesions
  • Malaise/lethargy or non-specific general deterioration
  • Loss of appetite
  • Inflammation, swelling of lymph glands
Systemic
  • Severe sepsis
  • Septic shock
  • Organ failure
  • Death
Data source: ©Wounds International. Adapted for this textbook with permission.

Factors that Increase the Risk of Wound Infection

Table 4.6 Considerations for Increased Risk of Wound Infection

Individual Factors

  • Poorly controlled diabetes
  • Prior surgery
  • Radiation therapy or chemotherapy
  • Conditions associated with hypoxia and/or poor tissue perfusion (e.g., anemia, cardiac or respiratory disease, arterial or vascular disease, renal impairment, rheumatoid arthritis, shock)
  • Immune system disorders (e.g., acquired immune deficiency syndrome, malignancy)
  • Inappropriate antibiotic prophylaxis, particularly in acute wounds
  • Protein-energy malnutrition
  • Alcohol, smoking, and drug abuse
  • +/- erythema Lymphangitis Crepitus
  • Age

Wound Factors

Acute wounds:
  • Contaminated or dirty wounds
  • Trauma with delayed treatment
  • Pre-existing infection or sepsis
  • Spillage from gastro-intestinal tract
  • Penetrating wounds over four hours
  • Inappropriate hair removal
  • Operative factors (e.g., long surgical procedure, hypothermia, blood transfusion)
Chronic wounds:
  • Degree of chronicity/duration of wound
  • Large wound area
  • Deep wound
  • Anatomically located near a site of potential contamination (e.g., perineum or sacrum)

Both wound types:

  • Foreign body (e.g., drains, sutures)
  • Hematoma
  • Necrotic wound tissue
  • Impaired tissue perfusion
  • Increased exudate or moisture

Environment Factors

  • Hospitalization (increased risk of exposure to antibiotic resistant organisms)
  • Poor hand hygiene and aseptic technique
  • Unhygienic environment (e.g., dust, unclean surfaces, mold/mildew in bathrooms)
  • Inadequate management of moisture, exudate, and edema
  • Inadequate pressure off-loading
  • Repeated trauma (e.g., inappropriate dressing removal technique)
Data source: © Wounds International. Adapted for this textbook with permission.

 

Critical Thinking Exercises

  1. Gerry is 58 years old. He has a history of smoking and hypertension, and has been in a motorcycle accident resulting in significant abrasions to his arms and legs. What factors increase Gerry’s risk of wound infection?
  2. JT is 38 years old. Has had paraplegia and a wound on the right ischium for 18 months. What factors increase JT’s risk of wound infection?
  3. What are the commonalities in relation to risk of wound infection and risk of impaired wound healing?

Attributions

Table 4.5 and 4.6 International Wound Infection Institute, 2016

38

4.4 Wound Management

The science of wound management has grown tremendously in recent years. As our understanding of wound healing has grown, so has the number of products used to manage wounds. For purposes of this textbook, brief discussions of different types of dressings are included. The reader is encouraged to further their understanding of wound healing through other sources and to seek the skills of wound care experts in practice.

 

Purposes of a dressing (Kerr et al, 2014):

Wound management occurs on a continuum from what many nurses refer to as simple dressing changes (such as a surgical wound) to complex wound management involving things like wound irrigation, vacuum assisted closure, and use of manufactured products designed for specific wound needs. The bottom line is that dressings have different purposes, and the dressing chosen should be appropriate to the wound’s needs.

Wound management follows the nursing process in terms of:

Terms that sometimes confuse people:

Aseptic technique: The purposeful prevention of the transfer of microorganisms from one person to another by keeping the microbe count to a minimum, and for assuring that cross-contamination does not occur. The technique chosen is based on dressing procedure, client setting, and agency policy. Principles of asepsis apply to all of them. There are three different applications of aseptic technique for the nurse to consider (British Columbia Provincial Nursing Skin & Wound Committee, 2011):

39

4.5 Simple Dressing Change

The healthcare provider chooses the appropriate sterile technique and necessary supplies based on the clinical condition of the patient, the cause of the wound, the type of dressing procedure, the goal of care, and agency policy.

Agency policy will determine the type of wound cleansing solution, but sterile normal saline and sterile water are the solutions of choice for cleansing wounds and should be at room temperature to support wound healing. The ideal cleansing agent and the optimal method of wound cleansing has not been established conclusively (International Wound Infection Institute, 2016). Some wound cleansing solutions include sterile water, sterile saline, tap water, chlorhexidine, and povidone/iodine. Each cleansing solution has characteristics that make it a good or poor choice in certain situations. The nurse should use the wound cleansing solution as directed by agency policy and/or wound specialists.

Surgical dressings should remain in place for at least 48 hours and should be reinforced if soiled. At the 48 hour point, the wound may be exposed to air, but this is dependent on a number of factors such as type of surgery, wound healing (wound edges must be approximated and the wound not leaking), comfort of the client with an exposed incision, and agency policy (BC Provincial Skin and Wound Committee, 2011).

Checklist 35 outlines the steps for performing a simple dressing change.

Checklist 35: Simple Dressing Change

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient; offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Perform point of care risk assessment for PPE
  • Sanitize your working surface.

Steps

 Additional Information

1. Assess current dressing. If you plan to touch the dressing, donne non-sterile gloves to protect yourself from exposure to BBF. Assess dressing for signs of shadowing / bleeding, type and size of dressing used.
Apply non-sterile gloves
Apply non-sterile gloves
2. Perform hand hygiene. Hand hygiene reduces risk of spread of microorganisms.
Perform hand hygiene
Perform hand hygiene
3. Gather necessary equipment. Dressing supplies must be for single patient use only. Use the smallest size of dressing for the wound.
Gather supplies
Gather supplies

Take only the dressing supplies needed for the dressing change to the bedside. Equipment that is contaminated at the bedside cannot return to general circulation to be used with other patients.

4. Prepare environment; position patient; adjust height of bed; and turn on lights. Ensure patient’s comfort prior to and during the procedure. Proper lighting allows for good visibility to assess wound.
5. Perform hand hygiene. Hand hygiene prevents spread of microorganisms.
Hand hygiene with ABHR
Hand hygiene with ABHR
6. Prepare sterile field.
Prepare sterile field
Prepare sterile field
7. Add necessary sterile supplies.
Add necessary supplies
Add necessary supplies
8. Pour cleansing solution.
Pour sterile cleansing solution into sterile tray
Pour sterile cleansing solution into sterile tray

Normal saline or sterile water containers must be used for only one client, and they must be dated and discarded within at least 24 hours of being opened.

9. Prepare patient and expose dressed wound.
Prepare patient and expose wound
Prepare patient and expose wound
10. Apply non-sterile gloves. Use non-sterile gloves to protect yourself from contamination.
Apply non-sterile gloves
Apply non-sterile gloves
11. Remove outer dressing with non-sterile gloves and discard as per agency policy.
Removing outer dressing with non-sterile gloves
Remove outer dressing with non-sterile gloves

The rationale for non sterile gloves is to protect you from exposure to BBF.

12. If necessary, remove inner dressing with transfer forceps.
DSC_0328
Remove inner dressing with transfer forceps
13. Discard transfer forceps & gloves
Discard transfer forceps
discard gloves
14. Assess wound Are the wound edges approximated? Are the staples / sutures intact? Is there evidence of complications?
14. Cleanse wound remembering principles of asepsis Clean to dirty; one wipe one way discard; fluids flow in the direction of gravity.

 

15. Cleanse around the drain if present Using a circular motion, clean the area immediately next to the drain and work outward  still following principles of asepsis

16. Apply new sterile dressing. The type of dressing applied will depend on the needs of the wound and the supplies available in the agency.

Secure dressings and drains with tape.

Write the date and time on the outside of the dressing as a way to inform others.

17. Ensure the patient is comfortable before leaving the bedside.

Perform hand hygiene.

 

Discard used equipment according to agency policy.
18. Document according to agency policy.

 

Consider the progression of wound healing. If concerned notify the prescriber.

Documentation example:

date / time: abdominal dressing changed. Moderate sanguinous drainage from distal end of incision. Wound well approximated. Staples intact. Cleansed with 0.9% NS. Dressed with medipore dressing. Patient tolerated well. ——- B. Dage RN

 

 

Data source: BCIT, 2010a; Perry et al., 2018
If necessary review Principles of Asepsis developed by Renée Anderson & Wendy McKenzie Thompson Rivers University.
Watch the video Simple Sterile Dressing Change developed by Renée Anderson and Wendy McKenzie Thompson Rivers University School of Nursing (2014).

40

4.6 Advanced Wound Care: Wet to Moist Dressing, and Wound Irrigation and Packing

Traditionally, when wounds required debridement wet to dry dressings were used. This involved applying moist saline or other solution (i.e., Dakin’s) to gauze, placing it into a wound bed, allowing it to dry, and then removing it. As the dressing is removed, so is the unhealthy tissue. The belief was that the removal of the dead tissue facilitated healing. As we have come to understand more about wound healing, we now know that this practice disrupts healthy tissue. Besides being detrimental to wound healing, it can also be painful for the patient. As such, this is not current best practice (Kerr et al., 2014).

We have come to understand that wound beds need a moist environment to heal. Wet to moist dressings provide a moist healing environment, but they can require several dressing changes each day to maintain that moisture. These frequent dressing changes come with personal cost to the patient, financial cost in terms of nursing time and supplies, risk of infection associated with frequent dressing changes, and potential damage to the wound bed if the dressing is allowed to dry out (Kerr et al., 2014).

A wet to moist dressing can be selected for a wound bed until further direction is given by someone with knowledge about wound products. The type of wound dressing used depends not only on the characteristics of the wound, but also on the goal of the wound treatment and ability to access products. Recalling factors that influence wound healing, the skill and knowledge of the healthcare professional (HCP) and their ability to diagnose, select appropriate treatments, and correctly implement treatments are important considerations in relation to wound care  (Norton et al., 2018; Harris et al., 2018).

Wet to Moist Dressing

A wet to moist dressing involves a primary dressing that directly touches the wound bed, and a secondary dressing covering it.

Important: Ensure pain is well managed prior to a dressing change to maximize patient comfort.

Checklist 36 outlines the steps for performing a wet to moist dressing change.

Checklist 36: Wet to Moist Dressing Change

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient and offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Perform a point of care risk assessment for PPE.
  • Sanitize your working surface.

Steps

 Additional Information

1. Check present dressing using non-sterile gloves if necessary. This provides an opportunity for assessment and to determine required supplies for the procedure.
2. Perform hand hygiene. Hand hygiene reduces the risk of infection.
Perform hand hygiene
Perform hand hygiene
3. Gather necessary equipment and supplies. Being organized will help with efficiency and expedite the procedure, minimizing the length of time the patient experiences discomfort.
4. Prepare environment; position patient; adjust height of bed; turn on lights; and sanitize working surface. This helps prepare patient and bedside for procedure.
5. Perform hand hygiene. Hand hygiene reduces the risk of infection.
Hand hygiene with ABHR
Hand hygiene with ABHR
6. Decide if this is a clean or sterile procedure. If a clean procedure, use non-sterile gloves. If a sterile procedure, use sterile gloves and follow principles of asepsis.

Prepare field.

Sterile field
Sterile field

Whether this is a sterile or clean procedure, always reduce risk of transmitting microorganisms to patients

7. Add necessary sterile supplies. If this is a sterile procedure, use sterile saline.

If you are irrigating the wound, you will need irrigation equipment (10 ml syringe and wound irrigation catheter).

Adding supplies
Add supplies
8. Pour cleansing solution into two separate compartments.

Place gauze and saline to be used for wound packing in its own compartment.

Pouring cleaning solution
Pour cleansing solution
9. Apply non-sterile gloves. This reduces the risk of contaminating your hands with the patient’s blood and other body fluids.

It also reduces the risk of germ transmission from you to the patient and vice versa, as well as from one patient to another.

Apply non-sterile gloves
Apply non-sterile gloves
10. Remove outer dressing with non-sterile gloves.
Removing outer dressing with non-sterile gloves
Remove outer dressing with non-sterile gloves
11. Remove inner dressing with transfer forceps, and assess the old dressing and the wound.
Remove inner dressing with forceps
Remove inner dressing with forceps

Inspect wound for evidence of healing or complications including the amount and type of drainage, odor, presence of staples / sutures, wound approximation, peri skin condition.

12. Discard transfer forceps and non-sterile gloves.
Discard transfer forceps
Discard transfer forceps
13. Drape patient with underpad (optional).
Drape patient with underpad
Drape patient with underpad
14. Clean the peri-wound skin and clean the wound bed either by irrigating or with sterile gauze and saline. Irrigating with 10 pounds per square inch (PSI) and/or wiping gently with sterile gauze helps to lift slough and clean the wound bed.
15. Apply sterile or clean gloves (depending if the nature of the wound calls for a clean or sterile procedure).

Wring-out excess solution from the gauze to be used for packing.

“Not too wet and and not too dry … just like your eye” (author unknown)

Use enough saline to saturate gauze. Too much moisture can cause the peri-wound skin to become macerated.
Saturate gauze
Saturate gauze
16. Fluff up the moist gauze. Place into wound ensuring the wound bed is in contact with the moisture. Ensure gauze does not touch peri-wound skin. Apply skin preparation to peri-wound skin if there is risk of skin breakdown.

 

17. Apply cover dressing. Secure with tape, stockinette, or  kling. Select a cover dressing that will help the gauze to remain moist until the next dressing change (i.e., one that won’t wick away all of the moisture and cause the gauze to dry out).
18. Discard gloves according to agency policy, and perform hand hygiene. Hand hygiene reduces the risk of infection.
Book pictures 2015 196
Discard gloves
19. Next:
  • Assist patient to comfortable position.
  • Lower patient’s bed.
  • Discard used equipment appropriately.
These steps ensure the patient’s continued safety.
20. Document procedure and findings according to agency policy.

Report any unusual findings or concerns to the appropriate healthcare professional.

Record dressing change: time, place of wound, wound characteristics, presence of staples or sutures, size, drainage type and amount, type of cleansing solution and dressing applied.

 

Sample charting:

date / time. Right lateral ankle dressing changed. Large amount of sero purulent drainage. No odor. Wound approx 2 cm × 3 cm × 0.5 cm. Wound bed 90 % yellow slough 10% red. Irrigated with 30 ml normal saline. Packed with 4×4 gauze moist with saline. Covered with ABD pad and secured with stockinette. Peri-wound skin intact. Tolerated well.  —————T Rex RN

Data sources: Perry et al., 2018; WHO, 2009

Wound Irrigation and Packing

Wound irrigation and packing refer to the application of fluid to a wound to remove exudate, slough, necrotic debris, bacterial contaminants, and dressing residue without adversely impacting cellular activity vital to the wound healing process (British Columbia Provincial Nursing Skin and Wound Committee, 2014, 2017).

Any wound that has a cavity, undermining, sinus, or a tract will require irrigation and packing. Open wounds require a specific environment for optimal healing from secondary intention. The purpose of irrigating and packing a wound is to remove debris and exudate from the wound, and encourage the growth of granulation tissue to prevent premature closure and abscess formation (Saskatoon Health Region, 2013). Depending on the severity of the wound, it can take weeks to months or years to complete the healing process. Packing should only be done by a trained healthcare professional and according to agency guidelines.

Contraindications to packing a wound include a fistula tract, a wound with an unknown endpoint to tunneling, a wound sinus tract or tunnel where irrigation solution cannot be retrieved, or a non-healing wound that requires a dry environment (Saskatoon Health Region, 2013).

The type of packing for the wound is based on a wound assessment, goal for the wound, and wound care management objectives. The packing material should fill the dead space and conform to the cavity to the base and sides. It is important to not over-pack or under-pack the wound. If the wound is over-packed, there may be excessive pressure placed on the tissue causing pain, impaired blood flow, and, potentially, tissue damage. If the wound is under-packed and the packing material is not touching the base and the sides of the cavity, undermining, sinus tract, or tunnel, there is a risk of the edges rolling and abscess formation (British Columbia Provincial Nursing Skin and Wound Committee, 2014).

The gauze used to pack a wound may be soaked with normal saline, ointment, or hydrogel, depending on the needs of the wound. Other types of packing material include gauze impregnated with polyhexaamethylene biguanide (PHMB), iodine (povidone and cadexomer), ribbon dressing, hydro-fiber dressing, alginate antimicrobial dressing, and a negative pressure foam or gauze dressing. Table 4.7 lists some wound care products and indications for each. If using ribbon gauze from a multi-use container, ensure each patient has their own container to avoid cross-contamination (British Columbia Provincial Nursing Skin and Wound Committee, 2014).

Additional guidelines to irrigating and packing a wound are listed in Table 4.8.

Wound Care Products

Table 4.7 Wound Care Products

Type

Indications

Non-adherent contact layer (i.e., Telfa, silicone, petroleum-based woven dressings) Allows the wound to drain with minimal disruption to the wound bed when the dressing is removed. Requires an outer dressing.
Hydrocolloid
  • Minimal absorption capability (not for highly draining wounds)
  • Good for autolytic debridement
  • Maintains moist wound bed
  • Impermeable to external contamination
  • Self-adhesive and pliable, so conforms to the body
  • Duration approx. 5 to 7 days
  • All gel must be removed between dressing changes
  • Not for infected or necrotic wounds
Hydrogel
  • Introduces moisture into the wound
  • Absorbs small amounts of exudate
  • Debrides wound by softening necrotic tissue
  • Does not adhere to wound base
  • Duration approx. 5 to 7 days
  • All gel must be removed between dressing changes
Calcium alginates
  • Manufactured from seaweed
  • Highly absorbent
  • Becomes a gel in presence of moisture
  • Available as sheet or rope form
  • Requires an outer dressing
  • Must be fitted to the wound bed and not in contact with peri-wound skin
Foams
  • Used for highly draining wounds
  • Autolytic debridement
  • Change frequency depends on wound drainage (1 to 3 days)
  • Not for infected wounds
  • Not for dry necrosis
Charcoal
  • Charcoal imbedded in product and is odour absorbent
  • Requires an outer dressing
Anti-microbials
  • Medical grade honey, silver, cadexomer iodine, alginates, foams, pastes
Negative Pressure Wound Therapy (NPWT)
  • Also knows as VAC dressing, vacuum assisted closure
  • Manages large amounts of exudate
  • Sub-atmospheric pressure applied to a wound bed promotes and accelerates healing
BHMB
  • Antimicrobial / antiseptic impregnated into guaze (strips or sheets) and foam dressings
Silver impregnated gauze / foams
  •  Silver is antimicrobial and promotes healing. Foam absorbs moisture
Combination products
  • Can include more than one of the above (e.g., silver and charcoal)
Data sources: Alavi et al., 2015; Eberlein & Assadian, 2010; Kerr et al., 2014; Munteanu et al, 2016; Wiegand et al., 2015

Table 4.8 General Guidelines for Irrigating and Packing a Complicated Wound

Guideline

 Additional Information

Aseptic technique Sterile technique or no-touch technique may be used for irrigating and packing a wound. The use of a specific technique is based on agency policy, condition of the client, heal-ability of the wound, invasiveness, and goal of the wound care. Sterile technique or no-touch technique must be used in all acute care settings. Clean technique may be used for chronic wounds in long-term-care and home settings.
Type of solution for irrigation The most common solution used is normal saline at room temperature, unless otherwise ordered. Check prescriber’s / wound care specialist’s orders.

Non-potable water should never be used for cleansing of post operative wounds. Boiled and cooled water is an acceptable alternative (Johanna Briggs Institute, 2006, as cited in Harris et al., 2018)

Wound irrigation The wound is irrigated each time the dressing is changed. See specific wound guidelines about volume used to irrigate. The volume of irrigation solution is dependent on the size of wound and amount of exudate. Usually “irrigate until clear.” The majority of irrigation fluid should be recovered. If not, stop and consult the prescriber or wound care specialist. Begin irrigation at one part of the wound and move methodically  looking for tunnels whilst irrigating. Note the placement of the tunnel (using a clock face i.e. 12 o’clock) and note the depth of each tunnel.
Irrigation pressure The pressure of irrigating must be strong enough to remove debris but not damage the new tissue. Generally, a 35 ml syringe with a 19 gauge blunt tip will provide sufficient PSI for irrigation.
Wound assessment Wound assessment must be done with each dressing change to ensure the product is adequately meeting the needs of the wound.
Swabbing the wound Swab for culture, if required. Always swab a wound after irrigation. See agency protocols for how to obtain a wound C&S.
Packing material Packing material must be removed with each dressing change. Only one piece of gauze or dressing material should be used in wounds with sinus tracts or tunneling to avoid the risk of retaining dressing/packing material. If there is a concern that packing is retained in the wound, contact the wound specialist or physician for follow-up.

Always leave a “tail” of the packing strip outside the wound. If more than one piece of packing is used, leave the tails outside the wound by securing the tails to the skin with a piece of Steri-Strip if needed.

Documentation Wound assessment and dressing change must be documented each time. Each wound requires a separate wound care sheet. Type and quantity of packing material (length or pieces), along with the number of inner and outer dressings should be recorded as per agency policy. For any cavity, undermining, sinus tract, or tunnel with a depth greater than 1 cm (> 1 cm), count and document the number of packing pieces removed from the wound, and the number of packing pieces inserted into the wound.
Communication A copy of the most recent wound care assessment and dressing change should be sent with patient upon transfer to another healthcare facility.
Use of sterile gloves for packing Sterile gloves may be used if packing a large or complex wound.
Data sources: British Columbia Provincial Nursing Skin and Wound Committee, 2014; Harris, 2017; Saskatoon Health Region, 2013

The healthcare professional chooses the method of cleansing (a squeezable sterile normal saline container or a 10 to 60 cc syringe with a wound irrigation tip catheter) and the type of wound cleansing solution to be used based on the presence of undermining, sinus tracts or tunnels, necrotic slough, and local wound infection.

Agency policy will determine the wound cleansing solution, and/or product to be used to impregnate the gauze to be packed into the wound. Generally sterile normal saline and sterile water are the solutions of choice. Warmed solutions may increase patient comfort (Harris et al., 2018)

Undermining, sinuses, and tunnels can only be irrigated when there is a known endpoint. Do not irrigate undermining, sinuses, or tunnels that extend beyond 15 cm unless directed by a physician or nurse practitioner (NP). If fluid is instilled into a sinus, tunnel, or undermined area and cannot be removed from the area, stop irrigating and refer to a wound specialist, physician, or NP.

Checklist 37 outlines the steps for irrigating and packing a wound.

Checklist 37: Wound Irrigation and Packing

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient and offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Containers with cleansing solution must be patient specific, and must be discarded after 24 hours.
  • Sanitize working surface.
  • Perform a point of care risk assessment for PPE.

Steps

 Additional Information

1. Review order for wound care. Confirm that prescriber’s orders are appropriate to wound assessment.
2. Perform hand hygiene. Hand hygiene reduces the risk of infection.
Hand hygiene with ABHR
Hand hygiene with ABHR
3. Gather necessary equipment and supplies:
  • Syringe (10 to 60 ml)
  • Cannula with needleless adaptor (a.k.a. irrigation catheter)
  • Irrigation fluid (usually saline)
  • Basin
  • Waterproof pad
  • Dressing tray
  • Scissors if wound packing materials must be cut
  • Skin barrier / protectant
  • Cotton tip applicators
  • Measuring guide
  • Outer sterile dressing
  • Packing gauze or packing as per physician’s orders

Some agencies provide a prepackaged sterile irrigation tray.

Being organized will help with efficiency and expedite the procedure, minimizing the length of time the patient experiences discomfort.
Gather supplies and set up sterile tray
Gather supplies and set up sterile tray
4. Position patient to allow solution to flow off patient.

Position patient so wound is vertical to the collection basin.

Position patient on side
Position patient on side
5. Place waterproof pad under patient.

Set up sterile field and supplies.

Protect patient’s clothing and bedding from irrigation fluid.
6. Remove outer dressing with non-sterile glove.

Using transfer forceps, remove inner dressing (packing) from the wound.

If the packing sticks, gently soak the packing with normal saline or sterile water and gently lift off the packing.

Confirm the quantity and type of packing is the same as recorded on previous dressing change.

Remove outer dressing
Remove outer dressing

Removing packing that adheres to the wound bed without soaking can cause trauma to the wound bed tissue.

If packing material cannot be removed, contact the physician, NP, or wound clinician.

If packing adheres to the wound, reassess the amount of wound exudate and consider a different packing material.

Remove inner dressing
Remove inner dressing

All packing must be removed with each dressing change.

7. Assess the wound.
  • Take measurements, including length, width, and depth.
  • For undermining or tunneling, note location and size.
  • Look for evidence of bone or tendon exposure.
  • Assess appearance of wound bed, noting percentage of tissue types.
  • Note presence of odor after cleansing.
  • Assess appearance of wound edge and peri-wound skin.
Assess the wound
Assess the wound

Wound assessment helps identify if the wound care is effective.

Always compare the current wound assessment with the previous assessment to determine if the wound is healing, delayed, worsening, or showing signs of infection.

8. Apply non-sterile gloves, gown, and goggles or face shield according to your point of care risk assessment. The use of personal protective equipment (PPE) reduces the risk of your exposure to BBF
Apply non-sterile gloves
Apply non-sterile gloves
9. Fill 35 to 60 ml syringe with sterile water or irrigating solution, and attach an irrigation tip to the end of syringe.
Fill syringe with irrigating solution
Fill syringe with irrigating solution
10. Hold the irrigation tip very close to the wound and flush wound using gently continuous pressure until returns run clear into the basin.

If irrigating a deep wound with a very small opening, attach an irrigation tip catheter to the syringe. Insert the tip searching for undermining and tunnels, measuring and noting the location and depth of each.

Use slow continuous pressure to flush wound.

Repeat flushing procedure until returns run clear into the basin. If the majority of the irrigation fluid is not recovered stop and consult the prescriber.

Irrigate wound
Irrigate wound

Irrigation should be drained into basin. Retained irrigation fluid is a medium for bacterial growth and subsequent infection.

Irrigation should not increase patient discomfort.

The irrigation tip controls the pressure of the fluid, not the force of the plunger.

11. Clean and dry wound edges with sterile gauze using sterile forceps.
Dry wound edges with sterile gauze
Clean & dry wound edges with sterile gauze

This step prevents maceration of surrounding tissue from excess moisture.

12. Remove goggles or face shield.
13. Perform hand hygiene and apply sterile gloves (if not using sterile forceps) or non-sterile gloves. Hand hygiene reduces the risk of infection.
Hand hygiene with ABHR
Hand hygiene with ABHR
14. For normal saline gauze packing:
  • Moisten the gauze with sterile normal saline, and wring it out so it is damp but not wet.
  • Enclose any non-woven edges in the centre of the packing material to reduce the risk of loose threads in the wound.

For other packing materials (e.g., hydrogel, iodine [povidone & cadexomer], PHMB), see the specific product information.

 

The wound must be moist, not wet, for optimal healing. Gauze packing that is too wet can cause tissue maceration, and it reduces the absorbency of the gauze.
Moisten gauze
Moisten gauze

If using normal saline gauze packing, it needs to be changed often throughout the day to prevent the gauze from drying out.

If it is necessary to use more than one ribbon packing piece, the pieces must be tied together using sterile gloves; ensure the knot(s) is secure.

15. Open gauze and gently pack it into wound using either forceps, the tip of a cotton swab stick, or sterile gloved hands. Begin with the deepest part of the wound and finish at the surface.

Ensure the wound is not over-packed or under-packed as this may diminish the healing process.

Apply skin protectant to peri-wound skin.

Continue to pack the wound until all wound surfaces are in contact with gauze.
Apply packing to wound
Apply packing to wound

Keep the moist dressing off of the peri-wound skin.

​Saturated packing materials and/or wound exudate may macerate or irritate unprotected peri-wound skin.

16. Always leave a “tail” of packing materials either clearly visible in the wound cavity or on the peri-wound skin.

Use a Steri-Strip to secure the packing tail to the peri-wound skin.

If two or more packing pieces have been knotted together, ensure that the knots are placed in the wound cavity, not in the undermining, sinus tract, or tunnel.

leave a “tail” of packing materials
Leave a “tail” of packing materials

If the knot is visible in the wound, it is less likely that a packing piece will be lost if the knot comes undone.

A knot exerting pressure on the wound surface may impair blood flow and potentially cause necrosis in the wound.

17. Apply an appropriate outer dry dressing, depending on the frequency of the dressing changes and the amount of exudate from the wound. Secure the dressing. The dressing on the wound must remain dry on the outside until the next dressing change to reduce risk of introducing more microorganisms into the wound.
Apply outer dressing
Apply outer dressing
18. Discard supplies and perform hand hygiene. This prevents the transfer of microorganisms.
Perform hand hygiene
Perform hand hygiene
19. Help patient back into a comfortable position, and lower the bed. This step optimizes patient safety.
20. Document wound assessment, irrigation solution, dressings used for packing, and patient response to the procedure.

Documentation should include date and time of procedure.

Report any unusual findings or concerns to the appropriate healthcare professional.

This allows for effective communication between healthcare providers.

Notify required healthcare providers if wound appears infected or is not healing as expected.

Sample charting: date / time. Abdominal wound dressing changed. Large amount foul smelling purulent drainage present. wound irrigated with 60 ml NS using irrigation tip catheter and syringe. 2 cm tunnel at 12 o’clock and 4 cm tunnel at 5 o’clock. Wound bed approx 1.5 cm × 2 cm × 0.5 cm. Wound bed 50 % red 50% yellow slough. Tunnels and wound bed packed with hydrogel soaked ribbon gauze approx 20 cm in total. Peri-wound skin macerated extending approx. 3 cm. Skin prep applied to same. Covered with ABD pad. Tolerated with some voiced discomfort.———————–YIkes RN

Data sources: BCIT, 2010b; Perry et al., 2018
Watch the video Wound Irrigation and Packing by Renée Anderson and Wendy McKenzie Thompson Rivers University.

The following links provide additional information about wound packing and wound measuring.

Read British Columbia Provincial Nursing Skin & Wound Committee’s Procedure: Wound Packing (2017) to learn more about wound packing procedure.
Take Vancouver Coastal Health Authority’s Wound Assessment course (2009) to learn more about wound measuring and assessment.

Critical Thinking Exercises

  1. Provide a rationale for selecting PPE when performing wound irrigation (eye protection; gown; non-sterile gloves; sterile gloves).
  2. Which elements are important to consider when assessing a closed surgical incision?
  3. What elements are important to consider when assessing an open wound?

41

4.7 Suture Removal

Sutures are tiny threads, wire, or other material used to sew body tissue and skin together. They may be placed deep in the tissue and/or superficially to close a wound. A variety of suture techniques are used to close a wound, and deciding on a specific technique depends on the location of the wound, thickness of the skin, degree of tensions, and desired cosmetic effect (Perry et al., 2014).

There are different types of sutures techniques. Some of these are illustrated in Figure 4.2. The most commonly seen suture is the intermittent or interrupted suture.

Figure 4.2 Suture techniques
Figure 4.3 Simple interrupted sutures

Sutures may be absorbent (dissolvable) or non-absorbent (must be removed). Non-absorbent sutures are usually removed within 7 to 14 days. Suture removal is determined by how well the wound has healed and the extent of the surgery. Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs.

The healthcare provider must assess the wound to determine whether or not to remove the sutures. The wound line must also be observed for separations during the process of suture removal. Removal of sutures must be ordered by the primary healthcare provider (physician or nurse practitioner). An order to remove sutures must be obtained prior to the procedure, and a comprehensive assessment of the wound site must be performed prior to the removal of the sutures by the healthcare provider.

Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. If the wound is well healed, all the sutures would be removed at the same time. Alternately, the removal of the remaining sutures may be days or weeks later (Perry et al., 2014). Checklist 38 provides the steps for intermittent suture removal.

Checklist 38: Intermittent Suture Removal

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient and offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Assess the patient risk of delayed healing and risk of wound dehiscence.
  • Perform a point of care risk assessment for necessary PPE.

Steps

 Additional Information

1. Confirm prescriber’s orders, and explain procedure to patient. Offer analgesic. Explaining the procedure will help prevent anxiety and increase compliance with the procedure.

Inform patient that the procedure is not painful, but the patent may feel some pulling of the skin during suture removal.

2. Gather appropriate supplies after deciding if this is a clean or sterile procedure. Clean techniques suffice if wounds have been exposed to the air and the wound is approximated and healing. You will need suture scissors or suture blade, forceps, receptacle for suture material (gauze, tissue, garbage bag), antiseptic swabs can be used for clean procedure, sterile dressing tray if this is a sterile procedure. Steri-Strips and outer dressing, if indicated.
3. Position patient appropriately and create privacy for procedure. Ensure proper body mechanics for yourself, and create a comfortable position for the patient.
4. Perform hand hygiene. Hand hygiene reduces the risk of infection.
Perform hand hygiene
Perform hand hygiene
5. If this is a sterile procedure, prepare the sterile field and add necessary supplies in an organized manner.

Note: If this is a clean procedure, you simply need a clean surface for your supplies. Some of your equipment will come in its own sterile package. Think about how you can reduce waste but still ensure safety for the patient.

This allows easy access to required supplies for the procedure.
Preparing sterile field
Prepare sterile field
6. If present, remove dressing using non-sterile gloves and inspect the wound. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling.

Pain should be minimal.

After assessing the wound, decide if the wound is sufficiently healed to have the sutures removed. If there are concerns, question the order and seek advice from the appropriate healthcare provider.

Assess wound
Assess wound
7. Remove non-sterile gloves and perform hand hygiene. This prevents the transmission of microorganisms.
Hand hygiene with ABHR
Hand hygiene with ABHR
8. If necessary, clean and dry the incision site according to agency policy.

Consider the purpose and need for cleaning a wound that has been exposed to air for an extended period.

This step reduces risk of infection from microorganisms on the wound site or surrounding skin.
Clean incision
Clean incision

Cleaning also loosens and removes any dried blood or crusted exudate from the sutures and wound bed.

9. Perform a point of care risk assessment. Apply clean non-sterile gloves if indicated. Alternatively you can use no touch technique

To remove intermittent sutures, hold scissors / blade in dominant hand and forceps in non-dominant hand.

 

This allows for dexterity with suture removal.
holHold scissors in dominant hand and forceps in non-dominant hand
Hold scissors in dominant hand and forceps in non-dominant hand
10. Grasp knot of suture with forceps and gently pull up knot. Note the entry / exit points of the suture material. Slip the tip of the scissors under suture near the skin. DSC_0257
11. Cut under the knot as close as possible to the skin at the distal end of the knot. If using a blade to cut the suture, point the blade away from you and your patient.
image
Cut under the knot

Key points:

  • Cut the suture at the surface of the skin.
  • Never leave suture material below the surface.
  • Do not pull the contaminated suture (suture on top of the skin) below the surface of the skin.

 

12. Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place removed sutures into the receptacle
image
Grasp knotted end with forceps
13. Remove every second suture until the end of the incision line. Assess wound healing after removal of each suture to determine if each remaining suture will be removed.
If wound edges open, stop the procedure, apply Steri-Strips (using tension to pull wound edges together), cover the wound, and notify appropriate healthcare providers. 

It is within the RN’s independent scope of practice to apply Steri-Strips to a wound without an order (BCCNP, 2019).

14. Using the principles of asepsis, place Steri-Strips perpendicular along the incision line with gaps of approximately 2 to 3 mm between each
Apply Steri-strips
Apply Steri-Strips
15. Apply appropriate sized Steri-Strips to provide support on either side of the incision, generally 2.5 to 5 cm. Steri-Strips support wound tension across wound and help to eliminate scarring.
Steri-strips
Steri-Strips
16. Remove remaining sutures.

 

Only remove remaining sutures if wound is well approximated.
Remove remaining sutures
Remove remaining sutures
17. Place Steri-Strips on remaining areas of each removed suture along incision line. The Steri-Strips will help keep the skin edges together.
Apply Steri-strips
Apply Steri-Strips
 

18. Complete patient teaching.

Instruct patient regarding:
  • Take showers rather than bathe.
  • Pat dry, do not scrub or rub the incision.
  • Do not pull off Steri-Strips. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to three weeks).
  • Importance of avoiding strain on the wound (i.e., if this is an abdominal wound, no straining during defecation; if this is a knee wound avoid kneeling).
  • Importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing.
  • Observe the wound for signs and symptoms of infection and notify a healthcare professional if any concerns.
19. Perform hand hygiene. Hand hygiene reduces risk of infection.
Hand hygiene with ABHR
Hand hygiene with ABHR
20. Document procedures and findings according to agency policy. Report any unusual findings or concerns to the appropriate healthcare professional.

 

Sample charting:

date/ time. Right hip sutures removed. Wound well approximated. No redness. No swelling. Steri-Strips applied. Aware of S&S of infection and to observe wound for same and report any concerns to the healthcare provider. Discussed showering, eventual removal of Steri-Strips, activity limitations for next 4 weeks. —————GNhome RN

 Data source: BCIT, 2010c; BCCNP 2019; Healthwise Staff, 2017; Perry et al., 2018
Watch the videos Intermittent Suture Removal   by Renée Anderson and Wendy McKenzie (2018) of Thompson Rivers University School of Nursing.

Critical Thinking Exercises

  1. Jasbir is going home with a lower abdominal surgical incision following a c-section. What patient teaching is important in relation to the wound?
  2. Acki is discharged from the clinic following removal of sutures in his knee following a mountain biking accident. What patient teaching is important in relation to the wound?
  3. What situations warrant staple / suture removal to be a sterile procedure? What situations warrant staple / suture removal to be a clean procedure?

Checklist 39 outlines the steps to remove continuous and blanket stitch sutures.

Checklist 39: Continuous and Blanket Stitch Suture Removal

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient and offer analgesia, bathroom etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Assess the patient risk of delayed healing and risk of wound dehiscence.
  • Perform a point of care risk assessment for necessary PPE.

Steps

 Additional Information

1. Confirm prescriber’s order and explain procedure to patient. Explaining the procedure will help prevent anxiety and increase compliance with the procedure.

Inform patient that the procedure is not painful, but the patent may feel some pulling of the skin during suture removal.

2. Gather appropriate supplies after deciding if this is a clean or sterile procedure. Clean techniques suffice if wounds have been exposed to the air and the wound is approximated and healing. You will need suture scissors or suture blade, forceps, receptacle for suture material (gauze, tissue, garbage bag), antiseptic swabs can be used for clean procedure, sterile dressing tray if this is a sterile procedure, Steri-Strips and outer dressing, if indicated.
3. Position patient appropriately and create privacy for procedure. Offer analgesic. Ensure proper body mechanics for yourself, and create a comfortable position for the patient.
4. Perform hand hygiene. Hand hygiene reduces the risk of infection.
Perform hand hygiene
Perform hand hygiene
5. If this is a sterile procedure, prepare the sterile field and add necessary supplies in an organized manner.

Note: If this is a clean procedure you simply need a clean surface for your supplies. Some of your equipment will come in its own sterile package. Think about how you can reduce waste but still ensure safety for the patient.

This step allows for easy access to required supplies for the procedure.
Preparing sterile field
Prepare sterile field
6. If present, remove dressing with non-sterile gloves and inspect the wound. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling.

Pain should be minimal.

Assess wound
Assess wound

After assessing the wound, decide if the wound is sufficiently healed to have the sutures removed. If there are concerns, question the order and seek advice from the appropriate healthcare provider.

7. Remove non-sterile gloves and perform hand hygiene. This step prevents the transmission of microorganisms.
Remove non-sterile gloves
Remove non-sterile gloves
8. If necessary, clean and dry the incision site according to agency policy. This step reduces the risk of infection from microorganisms on the wound site or surrounding skin.

Cleaning also loosens and removes any dried blood or crusted exudate from the sutures and wound bed.

Clean incision site
Clean incision site
9. Place receptacle close to suture line; grasp scissors in dominant hand and forceps in non-dominant hand. This allows for dexterity with suture removal.
10. Grasp the knot of the suture with forceps and gently pull up. Note the entry and exit points of the suture material.

Cut one of the suture strings.

Gently pull on the knot to remove the suture.

If suture isn’t removed, gently pull on suture material to determine the next entry / exit point.

 
continuous-suture-removal
Continuous suture removal guide
11. Snip second suture on the same side. Grasp knotted end and gently pull out suture. Place suture into receptacle. This action prevents the suture from being left under the skin.
12. Continue cutting in the same manner until the entire suture is removed, inspecting the incision line during the procedure. Inspection of incision line reduces the risk of separation of incision during procedure.
If separation occurs: Stop procedure, apply Steri-Strips and sterile dressing, and notify physician.
13. Apply Steri-Strips to suture line, then apply sterile dressing or leave open to air. This step reduces the risk of infection.
DSC_1658
Apply Steri-Strips
14. Position patient and lower bed to safe height; ensure patient is comfortable and free from pain. This ensures patient safety.
15. Complete patient teaching. Instruct patient regarding:
  • Take showers rather than bathe.
  • Pat dry, do not scrub or rub the incision.
  • Do not pull off Steri-Strips. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to three weeks).
  • Importance of avoiding strain on the wound (i.e., if this is an abdominal wound, no straining during defecation; if this is a knee wound avoid kneeling).
  • Importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing.
  • Observe the wound for signs and symptoms of infection and notify a healthcare professional if any concerns.
16. Discard supplies according to agency policies for sharp disposal and biohazard waste. In some agencies scissors and forceps may be disposed, in others they are sent for sterilization.
17. Perform hand hygiene. Hand hygiene reduces risk of infection.
Hand hygiene with ABHR
Hand hygiene with ABHR
18. Document procedures and findings according to agency policy. Report any unusual findings or concerns to the appropriate healthcare professional.
 Data source: BCIT, 2010c; Perry et al., 2014
Watch the video Continuous / Blanket Stitch Suture Removal developed by Renée Anderson and Wendy McKenzie (2018) Thompson Rivers University School of Nursing.

Complications related to suture removal, including wound dehiscence, may occur if wound is not well healed, if the sutures are removed too early, or if excessive force (pressure) is applied to the wound. In addition, if the sutures are left in for an extended period of time, the wound may heal around the sutures, making extraction of the sutures difficult and painful. Table 4.9 lists additional complications related to wounds closed with sutures.

Table 4.9 Complications of Suture Removal

Complication

Solution

Unable to remove suture from tissue Contact physician for further instructions.
Wound dehiscence: Incision edges separate during suture removal; wound opens up Stop removing sutures.

Apply Steri-Strips across open area and perpendicular to the wound.

Notify physician.

Patient experiences pain when sutures are removed Allow small rest breaks during removal of sutures.

Use distraction techniques (wiggle toes / slow deep breaths).

Offer analgesic.

Provide opportunity for the patient to deep breathe and relax during the procedure.

Wound becomes red, painful, with increasing pain, fever, drainage from wound These changes may indicate the wound is infected. Report findings to the primary healthcare provider for additional treatment and assessments.
Scarring related to sutures All wounds form a scar and will take months to one year to completely heal. Scarring may be more prominent if sutures are left in too long.
Keloid formation A keloid formation is a firm scar-like mass of tissue that occurs at the wound site. The scarring tends to extend past the wound and is darker in appearance.
Hypertrophic scars Hypertrophic scars are scars that are bulky but remain within the boundaries of the wound. These scars can be minimized by applying firm pressure to the wound during the healing process using sterile Steri-Strips or a dry sterile bandage.
Data sources: BCIT, 2010c; Perry et al., 2014

Critical Thinking Exercises

5. What is the purpose of applying Steri-Strips to the incision after removing sutures?

6. Which healthcare provider is responsible for assessing the wound prior to removing sutures?

7. What factors increase risk of delayed wound healing?

8. What patient teaching points should be included as ways to support wound healing?

Attributions

Figure 4.2 Suture techniques. Adapted from World Health Organization. Emergency & Essential Surgical Care Programme. [2018].  Emergency and Trauma Care Module 2: Basic surgical skills: Practical suture techniques. Used under the CC BY-NC-SA 3.0 IGO license.

Figure 4.3 Intermittent plain sutures by Jones, S. is used under the CC BY-SA 2.0 license.

42

4.8 Staple Removal

Staples are made of stainless steel wire and provide strength for wound closure. Staples are strong, quick to insert, and simple to remove.

Figure 4.4 Surgical staples

Removal of staples requires aseptic considerations and a staple extractor. An order to remove the staples, and any specific directions for removal (i.e., remove alternate staples only), must be obtained prior to the procedure. The healthcare professional performing the removal must also inspect the wound prior to the procedure to ensure the wound is adequately healed to have the staples removed. Usually every second staple is removed initially; then the remainder are removed at a later time (Perry et al., 2014). In general, staples are removed within 7 to 14 days.

Checklist 39 outlines the steps for removing staples from a wound.

Checklist 39: Staple Removal

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Check room for additional precautions.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient and offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Assess patient risk for delayed wound healing and potential dehiscence.
  • perform a point of care risk assessment for PPE

Steps

 Additional Information

1. Confirm prescriber’s orders, and explain procedure to patient. Explanation helps prevent anxiety and increases compliance with the procedure. Inform patient the procedure is not painful, but the patent may feel some pulling or pinching of the skin during staple removal.
2. Gather appropriate supplies after deciding if this is a clean or sterile procedure. Clean techniques suffice if wounds have been exposed to the air and the wound is approximated and healing. You will need staple remover, receptacle for suture material (gauze, tissue, garbage bag), antiseptic swabs can be used for clean procedure, sterile dressing tray if this is a sterile procedure. Steri-Strips and outer dressing, if indicated.
Figure 4.5 staple removal equipment
3. Position patient appropriately and create privacy for procedure. Ensure proper body mechanics for yourself, and create a comfortable position for the patient.
4. Perform hand hygiene. This reduces the risk of infection.
Perform hand hygiene
Perform hand hygiene
5. If necessary prepare the sterile field and add necessary supplies (staple extractor).

Note: If this is a clean procedure you simply need a clean surface for your supplies. Some of your equipment will come in its own sterile package. Think about how you can reduce waste but still consider safety for the patient.

This step allows easy access to required supplies for the procedure.
Add sterile items to sterile field
Add sterile items to sterile field
6 Apply non-sterile gloves.

If present, remove dressing and inspect the wound.

Visually assess the wound for uniform closure of the edges, absence of drainage, redness, and inflammation.
Remove dressing and inspect the wound
Remove dressing and inspect the wound

After assessing the wound, determine if the wound is sufficiently healed to have the staples removed. If concerns are present, question the order and seek advice from the appropriate healthcare provider.

7. If necessary, clean incision site according to agency policy. This reduces the risk of infection from microorganisms on the wound site or surrounding skin.
Clean incision site
Clean incision site

Cleaning also loosens and removes any dried blood or crusted exudate from the staples and wound bed.

 When removing staples, remove every other one first.
8. With the staple remover at an angle of less than 30º to the skin, place lower tip of staple extractor beneath the staple.

Do not pull up while depressing handle on staple remover or change the angle of your wrist or hand. Close the handle, observe the staple ends lifting out of the skin. If necessary, gently move the staple side to side to remove.

The closed handle depresses the middle of the staple causing the two ends to bend outward and out of the top layer of skin.
Close the handle, then gently move the staple from side to side to remove
Close the handle, then gently move the staple from side to side to remove
9. When both ends of the staple are visible, move the staple extractor away from the skin and place the staple on a receptacle by releasing the handles on the staple extractor. This avoids pulling the staple out prematurely and avoids putting pressure on the wound. It also prevents scratching the skin with the sharp staple.
Keep the handle closed and move the staple extractor away from the skin
Keep the handle closed and move the staple extractor away from the skin
10. Continue to remove every second staple to the end of the incision line. Alternating removal of staples provides strength to incision line while removing staples and prevents accidental separation of incision line.
Continue to remove every second staple to the end of the incision line
Continue to remove every second staple to the end of the incision line
11. If necessary, apply Steri-Strips.

Apply appropriate sized Steri-Strips to provide support on either side of the incision, generally 1 to 2 in long.

Using the principles of asepsis, place Steri-Strips perpendicular along the incision line with gaps of approximately 2 to 3 mm between each.

 

Steri-Strips support wound tension across wound and eliminate scarring.

This allows wound to heal by primary intention.

Cut Steri-Strips to allow them to extend 1.5 to 2 cm on each side of incision
Cut Steri-Strips to allow them to extend 1.5 to 2 cm on each side of incision
12. Remove remaining staples, followed by applying Steri-Strips along the incision line. Steri-Strips support wound tension across wound
13. If necessary, apply dry, sterile dressing on incision site or leave exposed to air if wound is not irritated by clothing, or according to physician orders. This reduces risk of infection.
Apply dry sterile dressing if required
Apply dry, sterile dressing if required
14. Position patient, lower bed to safe height, and ensure patient is comfortable and free from pain. This provides patient with a safe, comfortable place, and attends to pain needs as required.
15. Complete patient teaching. Instruct patient regarding:
  • Take showers rather than bathe.
  • Pat dry, not scrub or rub the incision.
  • Do not pull off Steri-Strips. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to three weeks).
  • Importance of avoiding strain on the wound (i.e., if this is an abdominal wound, no straining during defecation; if this is a knee wound, avoid kneeling; etc.).
  • Importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing.
  • Observe the wound for signs and symptoms of infection and notify a healthcare professional if any concerns.
16. Discard supplies according to agency policies for sharps disposal and biohazard waste. Staple extractor may be disposed of or sent for sterilization.
17. Perform hand hygiene and document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate healthcare professional. Hand hygiene reduces the risk of infection.
Hand hygiene with ABHR
Hand hygiene with ABHR
Data source: BCIT, 2010c; Perry et al., 2014
Watch the video Staple Removal developed by Renée Anderson and Wendy McKenzie (2018) of TRU School of Nursing.

Staple removal may lead to complications for the patient. When removing staples, consider the length of time the staples have been in situ. Wound dehiscence, a mechanical failure of wound healing, remains a problem and can be affected by multiple factors (Spiliotis et al., 2009). Obese patients (greater than 30 kg/m2) have a higher risk of dehiscence than patients with a normal BMI. Additional risk factors for dehiscence include age over 75 years, COPD, diagnosis of cancer, use of steroids, malnutrition, anemia, sepsis, obesity, diabetes, tobacco use, and previous administration of chemotherapy or radiotherapy (Spiliotis et al., 2009).

Table 4.10 lists other complications of removing staples.

Table 4.10 Potential Complications of Staple Removal

Complication

Solution

Unable to remove staple from tissue Contact physician for further instructions.
Dehiscence: Incision edges separate during staple removal Stop removing staples.

Apply Steri-Strips across open area.

Notify physician.

Patient experiences pain when staples are removed Allow small breaks during removal of staples.

Use distraction techniques.

Provide opportunity for the patient to deep breathe and relax during the procedure.

Data source: BCIT, 2010c; Perry et al., 2018

Critical Thinking Exercises

  1. You are about to remove your patient’s abdominal incision staples according to the prescriber’s orders. As you start to remove the staples, you notice that the skin edges of the incision line are separating. What would be your next steps?
  2. Your patient informs you that he is feeling significant pain as you begin to remove his staples. What would you do next?

Attributions

Figure 4.4 Surgical staples after total hip replacement by Karl-Heinz Wellmann, Wikipedia is used under the CC BY 3.0 license.

43

4.9 Drain Management and Removal

Drain Management

Drain systems are a common feature of post-operative surgical management and are used to remove drainage from a wound bed to prevent infection and the delay of wound healing. A drain may be superficial to the skin or deep in the tissue, duct, or cavity. The number of drains depends on the extent and type of surgery. Active drains are closed systems that use vacuum action to withdraw fluids from the site into a collection reservoir. The drainage tube is a silastic tube with perforations to allow fluid to be sucked away from the site. Closed systems should be emptied when they are 1/3 to 1/2 full to allow the drain to function optimally. At minimum they should be emptied and measured at least once every shift, and the ports cleaned according to agency policy. These drains are very common and are referred to as Hemovac or Jackson Pratt (Perry et al., 2018).

Hemovac drains (see Figure 4.5) can hold up to 500 ml of drainage. A Jackson Pratt (JP) (see Figure 4.6) is used for wounds anticipated to have  smaller amounts of drainage. Drains are often sutured to the skin to prevent accidental removal. The drain insertion site is covered with a sterile dressing. Assessment of drain functioning periodically throughout the day is important. These types of drains are referred to as active drains because of the suction action used to remove drainage. They are also referred to as closed wound drains because the drain system is closed.

Passive drains, also known as capillary drains, work by providing an opening from the area of concern to the outside of the body. Gravity and body movement allow excess fluid to simply escape through the opening. Penrose drains are pieces of surgical tubing inserted into a surgical site, secured with a suture on the skin surface, and they drain into a sterile dressing (Perry et al., 2018). Care and maintenance includes frequent dressing changes and attention to the peri-wound skin, which is at risk for breakdown in the presence of ++ moisture. Removal of capillary drains requires attention to avoid losing the drain into the patient’s body when the securing suture is released.

Pigtail drains (see Figure 4.7) are another type of passive drain. They are a type of tubing inserted into the site, held in place by the tube’s curl at the end. These can also be sutured on the skin surface. Pigtail drains are attached to a drainage bag and are often used to manage the treatment of abscesses (RSNA, 2018).

Figure 4.5 Hemovac drain
Figure 4.6 Jackson Pratt drain
Figure 4.7 Pigtail drain

Checklist 40 outlines the steps to take when emptying a closed wound drainage system.

Checklist 40: Emptying a Closed Wound Drainage System

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • Perform hand hygiene.
  • Point of care risk assessment for PPE.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Complete QPA including safety.
  • Explain process to patient and offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.

Steps

Additional Information

1. Perform hand hygiene. Hand hygiene reduces the risk of infection
Perform hand hygiene
2. Collect necessary supplies. For example: drainage measurement container, non-sterile gloves, waterproof pad, alcohol swab
3. Apply non-sterile gloves and goggles or face shield according to agency protocols and/or point of care risk assessment. PPE reduces the transmission of microorganisms and protects against accidental body fluid exposure.
Apply non-sterile gloves
4. Maintaining principles of asepsis, remove plug from pouring spout as indicated on drain. Open plug while pointing away from your face to avoid an accidental splash of body fluid.

Maintain asepsis in relation to the plug.

The vacuum will be broken and the reservoir (drainage collection system) will expand.

Open drain with opening facing away from you
5. Gently tilt the opening of the reservoir toward the measuring container and pour out contents. Note character of drainage: colour, consistency, odour, and amount. Pour away from yourself to prevent exposure to body fluids. Drainage counts as patient fluid output and must be documented on the patient chart as per hospital protocol.

Monitor drains frequently in the post operative period to reduce the weight of the reservoir and to monitor drainage. A recommendation is to empty when 1/3 to 1/2 full because they get heavy.

6. Swab the surface of the pouring spout and plug with an alcohol swab. Place drainage container on bed or hard surface, tilt away from your face, and compress the drain to flatten it with one hand.
Expel air from JP drain and flatten it before closing
Expel air from Hemovac drain and flatten it before closing
7. Place the plug back into the pour spout of the drainage system, maintaining asepsis. This establishes vaccum suction for drainage system
Place the plug into the pour spout of the JP drain maintaining principles of asepsi
Place the plug back into the pour spout of the Hemovac drain maintaining principles of asepsis
8. Secure device onto patient’s gown using a safety pin; ensure drain is functioning; ensure that enough slack is present on tubing. Securing drain decreases risk of inadvertent removal. Providing enough slack to accommodate patient movement prevents tension at the drain insertion site.
9. Discard drainage according to agency policy. Protection of HCWs against exposure to BBF.
10. Remove gloves and perform hand hygiene. Hand hygiene must be performed after removing gloves. Gloves are not puncture-proof or leak-proof, and hands may become contaminated when gloves are removed.
Remove gloves
Hand hygiene with ABHR
11. Document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate healthcare professional. This allows for accurate recording of drainage.

If more than one drain is present, number them, note their location in the chart. Chart each one separately.

If the amount of drainage increases or changes, notify the appropriate healthcare provider according to agency policy.

If the amount of drainage significantly decreases, the drain may be ready to be removed.

Data sources: BCIT, 2010b; Perry et al., 2018

Removal of a drain must be ordered by the prescriber. A drain is usually in place for 24 to 48 hours, and removal depends on the amount of drainage over the previous 24 hours.

Drain Removal

Checklist 41 outlines the steps for removing a wound drainage system (hemovac and JP) ** this is not the guidelines for removal of pigtail drains. Refer to your agency policy.

Checklist 41: Drain Removal

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Point of care risk assessment and selection of PPE.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient and offer analgesia, bathroom, etc.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Complete QPA including safety.
  • Sanitize your working surface.

Steps

Additional Information

1. Confirm that the prescriber order correlates with the amount of drainage in the past 24 hours. The prescriber should specify an amount for acceptable drainage for the drain to be removed. When in doubt, ask.
2. Explain procedure to patient; offer analgesia and bathroom as required. Taking this step decreases the patient’s anxiety about the procedure. Explain to the patient that a puling sensation may be felt but will stop after the procedure is complete.

Analgesia provides comfort and achieves the goal of an acceptable pain level for the procedure.

3. Assemble supplies at patient’s bedside: dressing tray, sterile suture scissors or sterile blade, cleansing solution, tape, garbage bag, outer dressing. Organizing supplies helps the procedure occur as efficiently as possible for the patient.
4. Apply a waterproof drape or pad for setting the drain onto once it has been removed. This provides a place to put the drain once it is removed.
5. Perform hand hygiene. Reduces risk of introducing microorganisms from elsewhere to the patient.
Hand hygiene with ABHR
6. Apply non-sterile gloves and PPE according to Point of Care Risk Assessment.
Apply non-sterile gloves
7. Release suction on reservoir and empty; measure and record volumes greater than 10 ml.

Remove dressing.

Release suction on the reservoir
8. Clean and dry the incision and drain site following principles of asepsis. Prepares the wound and surrounding tissue, may reduce microorganism counts.
9. Carefully cut and remove the securing suture following principles of asepsis. If you forget to cut the suture, the drain will be stuck.
10. While holding two to three 4 × 4 sterile gauze in non-dominant hand, stabilize skin. Sometimes additional drainage oozes out during drain removal. Sterile gauze provides a barrier to decrease risk of introducing microorganisms into the wound. Counter-pressure to the skin near the drain decreases discomfort to the patient.

Consider the use of sterile gloves if there is risk of introducing bacteria into the wound during drain removal.

11. Ask patient to take a deep breath and exhale slowly; remove the drain as the patient exhales.

Firmly grasp the drainage tube close to the skin with dominant hand, and with a swift and steady motion withdraw the drain.

Distraction helps the patient prepare for drain removal. Slight resistance may be felt. If there is strong resistance, hold your pull and ask the patient to take a deep breath. Sometimes the muscles need a little encouragement to relax. If you still can’t remove it, stop and call the prescriber.

Gather up the drain tubing in your hand as it is being removed.

When removed, ensure the drain tubing and the tip are intact.

12. Place drain and tubing onto waterproof pad or into garbage bag. Remove gloves. Prevents the drain and tubing from contaminating the bed or floor.
13. At this point some nurses will clean and dry the wound. The nurse can decide depending on the situation.
14. Dress the wound with sterile dressing. Drain sites often drain for a few days after. Consider adding some gauze under the cover dressing for extra absorbency.
Dress the wound with a sterile dressing
15. Discard drain and garbage as per agency policy. Decreases risk of BBF exposure to others.
16. Perform hand hygiene
Hand hygiene with ABHR
17. Assess dressing 30 minutes after drain removal. Likewise, ask the patient to call if they notice any increased drainage from the site. Monitor for excessive drainage from the drain site.
18. Document procedure (including drain removal, drain output and characteristics, how the patient tolerated the procedure, dressings applied) or according to agency policy. Report any unusual findings or concerns to the appropriate healthcare professional. Accurate and timely documentation and reporting promotes patient safety.

 

Sample charting:

date / time: JP drain to RLQ site cleansed with NS. 5 ml sanguinous drainage in past 24 hours. Securing suture removed. Drain removed. Tip intact. Site free of complications. Site dressed with 4-  2×2 guaze and Medipore™. Patient tolerated well.——————————–R.Barns RN

Data sources: BCIT, 2010b; Interior Health, n.d.; Perry et al., 2018; Saskatoon Health Region, 2012

Watch the video JP Drain Removal developed by Renée Anderson & Wendy McKenzie Thompson Rivers University School of Nursing (2014).

Critical Thinking Exercises

  1. When you start to remove your patient’s Jackson Pratt drain, you notice there is 100 ml of fresh blood in the drainage bulb. What would be your next steps?
  2. Describe ways in which you can help relieve the discomfort felt by a patient while removing a wound drain.

Attributions

Figure 4.7 Pigtail drain by Agency for Clinical Innovation is used under a CC BY 4.0 license.

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4.10 Summary

Wound healing is a complex process. To ensure optimal wound healing, it is essential to identify and control underlying issues that may prevent a wound from healing. Controlling blood sugar levels, limiting smoking, and observing proper nutrition all have a significant impact on the healing process. It is important to educate patients on these modifiable risk factors to promote wound healing. Understanding the process of wound healing, the use of a comprehensive assessment, and the appropriate selection of wound care products can maximize the wound healing process.

Key Takeaways

  • Wound care requires a complete assessment prior to initiating wound treatment. Always compare assessments with previous findings to assess whether wound is healing and if wound treatment is effective.
  • Treat the patient (modifiable external and internal factors) and the wound to optimize the healing process.
  • Select the appropriate wound treatment based on the wound characteristics, type of wound.
  • Understand the differences between types of wounds and causes, and follow procedures for best practice in the acute and clinical setting.

Suggested Online Resources

  1. Canadian Association of Wound Care (CAWC): Education. This website offers an education section for health care professionals using various methods to provide flexible, interprofessional education that supports the learning needs and professional career growth in the areas of skin health, wound prevention, and management.
  2. Connecting Learners with Knowledge (CLWK). This website started as a pilot project in 2010 and was created by nurses to explore innovative ways to meet their education needs. Membership grew considerably, and it soon became a permanent, living resource. In February 2014 it merged with QExchange.ca, which was home to communities for British Columbia health care providers. CLWK is now a growing group of communities that support health care providers as they network and improve care.
  3. Connecting Learners with Knowledge (CLWK): Skin & wound care. These interactive e-learning modules cover skin and wound care and each take about 25 to 30 minutes to complete.
  4. Provincial Infection Control Network of British Columbia (PICNET). This is the website for PICNET, a program of the Provincial Health Services Authority. Its mission is to reduce health care-associated infections by improving infection prevention control practices.
  5. Vancouver Coastal Health: How wounds heal. This 30-minute video is designed for health care professionals who wish to improve their understanding of wound and skin care. Information includes the definition of a wound, the three classifications of wound healing or closure, the trajectory of wound healing, and reasons for delayed wound healing.
  6. Vancouver Coastal Health: Wound assessment. This 30-minute video is designed for health care professionals who wish to improve their understanding of wound and skin care. Information includes basic wound etiology, wound location, and wound assessment parameters.

References

Agency for Clinical Innovation. (n.d.). Pigtail drain with thread formation of pigtail shape [Photo]. Retrieved from https://www.aci.health.nsw.gov.au/resources/respiratory/pleural-drains/pleural-drains-in-adults/section-1-pre-insertion/tube-selection.

Alavi, A., Archibald, G., Botros, M., Brassard, A., Coutts, P. M., Cross, K., … Woo, K. (2015). Summary of An Overview of Advanced Therapies in the Management of Diabetic Neuropathic Foot Ulcers. Wound Care Canada, 13(2), 10-17. Retrieved from https://www.woundscanada.ca/docman/public/wound-care-canada-magazine/2015-vol-13-no-2/546-wcc-fall-2015-v13n2-advanced-therapies/file.

British Columbia College of Nursing Professionals. (2019).  RN scope of practice standards | Autonomous scope and client-specific orders. Retrieved  from https://crnbc.ca/Standards/Lists/StandardResources/804ScopeStandards.pdf.

British Columbia Institute of Technology (BCIT). (2010a). Simple dressing change. Skills checklists.

British Columbia Institute of Technology (BCIT). (2010b). Drain removal. Skills checklists.

British Columbia Institute of Technology (BCIT). (2010c). Removal of sutures and staples. Skills checklists.

British Columbia Provincial Nursing Skin and Wound Committee. (2011). Guideline: Assessment and treatment of surgical wounds healing by primary and secondary intention in adults & children. Retrieved from https://www.clwk.ca/buddydrive/file/guideline-surgical-wounds-primary-secondary-intention/.

British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guidelines: Braden scale for predicting pressure ulcer risks in adults and children/infants. Retrieved from https://www.clwk.ca/buddydrive/file/guideline-braden-risk-assessment/.

British Columbia Provincial Nursing Skin and Wound Committee. (2017). Procedure: Wound packing. Retrieved from https://www.clwk.ca/buddydrive/file/procedure-wound-packing/.

Gallagher-Camden, S. (2012). Skin care needs of the obese patient. In R. A. Bryant & D. P. Nix (Eds.), Acute and chronic wounds: Current management concepts (4th ed.). St. Louis, MO: Mosby.

Häggström, M. (2010). Phases of wound healing. Limits vary within faded intervals, mainly by wound severity [Infographic]. Wikimedia Commons. Retrieved from https://commons.wikimedia.org/wiki/File:Wound_healing_phases.svg.

Harris, C., Kuhnke, J., Haley, J., Cross, K., Somayaji, R., Dubois, J., … Lewis, K. (2018). Best practice recommendations for the prevention and management of surgical wound complications. Canadian Association of Wound Care. Retrieved from https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/555-bpr-prevention-and-management-of-surgical-wound-complications-v2/file.

Healthwise Staff. (2017, May 16). Incision care after surgery. Retrieved from Government of British Columbia, HealthLinkBC website: https://www.healthlinkbc.ca/health-topics/tc4128spec.

Interior Health. (2016). Infection prevention and control manual. Retrieved from https://www.interiorhealth.ca/AboutUs/QualityCare/IPCManual/Entire%20Infection%20Control%20Manual.pdf.

International Wound Infection Institute (IWII). (2016). Wound infection in clinical practice. Wounds International. Retrieved from http://www.woundinfection-institute.com/wp-content/uploads/2017/07/IWII-Consensus_Final-2017.pdf.

Jones, S. (2007). 5 stitches on the finger [Photo]. Wikimedia Commons. Retrieved from https://commons.wikimedia.org/wiki/File:Stitches_2.jpg.

Kerr, J. R., Wood, M., Astle, B., & Duggleby, W. (2014). Canadian fundamentals of nursing (5th ed.). Toronto, ON: Elsevier.

Munteanu, A., Florescu, I., Nitescu, C. (2016). A modern method of treatment: The role of silver dressings in promoting healing and preventing pathological scarring in patients with burn wounds. Journal of Medicine and Life,  9(3). Pp 306-315. PMID: 27974941

Norton, L., Parslow, N., Johnston, D., Ho, C., Afalavi, A., Mark, M., … Moffat, S. (2018). Best practice recommendations for the prevention and management of pressure injuries. Canadian Association of Wound Care. Retrieved from https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/172-bpr-prevention-and-management-of-pressure-injuries-2/file.

Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical skills and nursing techniques (8th ed.). St. Louis, MO: Elsevier-Mosby.

Perry, A., Potter, P., & Ostendorf, W. (2018). Clinical skills and nursing techniques (9th ed.). St. Louis: Elsevier-Mosby.

Radiology Society of North America (RSNA). (2018). Percutaneous abscess drainage. Information for patients. Retrieved from https://www.radiologyinfo.org/en/info.cfm?pg=percabscessdrn.

Saskatoon Health Region. (2013). Drains: Emptying, shortening and removal. Policies and procedures. Retrieved from https://www.saskatoonhealthregion.ca/about/NursingManual/1100.pdf.

Spiliotis, J., Tsiveriotis, K., Datsis, A. D., Vaxevanidou, A., Zacharis, G., Giafis, K., … Rogdakis, A. (2009). Wound dehiscence: Is still a problem in the 21st century: A retrospective study. Retrieved from http://www.wjes.org/content/4/1/12.

Stotts, N. A. (2012). Nutritional assessment and support. In R. A. Bryant & D. P. Nix (Eds.), Acute and chronic wounds: Current management concepts (4th ed.). St. Louis, MO: Mosby.

Vancouver Coastal Health Authority. (2009). Wound assessment course. Retrieved from http://ccrs.vch.ca/onlinecourses/wound_management/woundassessment_v4/index.html.

Wellmann, K.-H. (2013). Surgical staples after totel hip replacement (right thigh), 13th day after surgery [Photo]. Wikimedia Commons. Retrieved from https://commons.wikimedia.org/wiki/File:Hip_replacement,_surgical_staples_01.JPG.

Wiegand, C., Tittelbach, J., Hipler, U., & Elsner, P. (2015). Clinical efficacy of dressings for treatment of heavily exuding chronic wounds. Chronic Wound Care Management and Research, (2), 101-111. https://doi.org/10.2147/CWCMR.S60315.

World Health Organization. (2009). Glove use information leaflet. Retrieved from http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf.

World Health Organization. (n.d.). Practical suture techniques. Retrieved from http://www.who.int/surgery/publications/s16383e.pdf.

V

Chapter 5. Oxygen Therapy

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5.1 Introduction

Oxygen is essential for sustaining life. The cardiovascular and the respiratory systems are responsible for supplying the body’s oxygen demands. Blood is oxygenated through the mechanisms of ventilation, perfusion, and the transport of respiratory gases (Potter, Perry, Ross-Kerr, & Wood, 2010).

Respiration is optimal when sufficient oxygenation occurs at the cellular level and when cellular waste and carbon dioxide are adequately removed via the bloodstream and lungs. If this system is interrupted — for example by lung tissue damage, inflammation or excess mucus in the airways, or impairment of ventilation — intervention is required to support the client and prevent the condition from worsening or, potentially, to prevent death from occurring (Perry, Potter, & Ostendorf, 2018).

Oxygen is the most frequently used medication in emergency medicine, and when used appropriately in the treatment of hypoxemia (an inadequate supply of oxygen in the arterial blood), it potentially saves lives (Kane, Decalmer, & O’Driscoll, 2013). This chapter describes the principles of oxygen therapy, the causes and management of hypoxia (the reduction of oxygen supply at the tissue level), and the optimal use of oxygen therapy and treatment modalities.

Learning Outcomes

  • Describe four functional components of the respiratory system.
  • Identify health conditions that pose a risk to adequate oxygenation.
  • Describe the functions and limitations of pulse oximetry.
  • Differentiate hypoxemia and hypoxia.
  • List hazards, precautions, and complications of oxygen therapy.
  • Recognize signs and symptoms of hypoxia and safely administer oxygen within one’s professional scope of practice.
  • Identify benefits and risks associated with oral and oropharyngeal suctioning.
  • Recognize signs and symptoms that suggest need for suctioning.
  • Demonstrate competence in relation to:
    • Oral suctioning
    • Oropharyngeal suctioning

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5.2 Oxygenation

In order for the nurse to understand the need to administer supplemental oxygen to a patient, a brief review of how we breathe and factors that affect oxygenation might be helpful. Supplemental oxygen is considered a medication and therefore requires continuous monitoring of the dose, concentration, and side effects to ensure its safe and effective use (Alberta Health Services, 2015). Oxygen therapy may be indicated for hypoxemia and hypoxia.

The air we breathe is made up of various gases, 21% of which is oxygen (Alberta Health Services, 2015). Therefore, a patient who is receiving no supplemental oxygen therapy is still receiving oxygen from the air. This amount of oxygen is adequate provided that the patient’s airway is not compromised and there is sufficient hemoglobin in the blood. The cardiovascular system must also be intact and able to circulate blood to all body tissues. If any of these systems fail, the patient will require supplemental oxygen to increase the likelihood that adequate levels of oxygen will reach all vital body tissues necessary to sustain life.

McCance, Huether, Brashers, and Rote (2014) describe four functional components of the respiratory system, all of which work in a concerted effort with the circulatory system to help our bodies maintain oxygenation. Table 5.1 outlines the four components and provides some explanation and health conditions that might present challenges with each.

Table 5.1 Four Functional Components of the Respiratory System & Health Conditions that Might Present Challenges in Terms of Increasing Risk of Impaired Oxygenation

Neurochemical control of ventilation (respiratory center, chemoreceptors) Ventilation is the movement of gases into and out of the lungs (Astle & Duggleby, 2019). The central nervous system controls ventilation by responding to signals from different neurochemicals (blood pH, PaCO2, PaO2 and others) at chemoreceptor sites located in different blood vessels. Some patients rely on the CO2 drive to breathe, and as such too much supplemental oxygen can cause them to stop breathing (Abdo & Heunks, 2012).
Mechanics of breathing (accessory muscles, lung elasticity, airway resistance, surface tension in alveoli, work of breathing) Breathing is often effortless. Many people don’t realize that muscles like our diaphragm and intercostals muscles play a role in our ability to adequately oxygenate. Anything that can affect chest wall movement has the potential to affect ventilation. Some examples include pregnancy, obesity and chest wall trauma. Neuromuscular disorders can affect the diaphragm and intercostals muscle function as can medications like anesthetics (Astle & Duggleby, 2019). Certain lung diseases result in lost lung elasticity, and as such the work of breathing is increased as the lungs expand during inspiration and try to return to resting volume during expiration. Airway resistance might be caused by airway swelling, obstruction, and bronchospasm. Surfactant, a type of protein in our alveoli, prevents the alveoli from collapsing when we exhale. When surfactant is inadequate, the work of breathing is increased as the body tries to open the alveoli during inspiration to achieve adequate oxygenation. (McCance et al., 2014). Such is the case with many premature babies. If the mechanics of breathing is challenged, so is the work of breathing.
Gas transport (distribution of ventilation and perfusion, O2 and CO2 transport) Oxygen is delivered to the cells and CO2 taken away. When caring for individuals nurses must consider if ventilation (exchange of air from the environment to the lungs) and perfusion (the amount of oxygen getting to the lungs) are adequate to meet the oxygen demands. O2 and CO2 exchange are impeded when the alveolar capillary membranes are thickened from conditions like pulmonary edema, pulmonary infiltrates, emphysema, and pneumothorax (McCance et al., 2014). Likewise persons with low Hgb may be challenged to meet their oxygen requirements (Astle & Duggleby, 2019). Some persons with chronic lung disease have abnormally high Hgb levels as a compensatory mechanism to help them achieve normal oxygen levels (McCance et al., 2014).
Control of pulmonary circulation (distribution of pulmonary blood flow) Vasoconstriction of the vessels in pulmonary circulation can be the result of alveolar hypoxia. Possible causes of this hypoxia include obstruction, metabolic and respiratory acidosis, and other biochemical factors (histamine, prostaglandins, bradykinin, and others) (McCance et al., 2014).
Data sources: Abdo & Heunks, 2012; Astle & Duggleby, 2019

Hemoglobin

We rely on hemoglobin (Hgb) for gas transport. It holds oxygen in reserve until the metabolic demands of the body require more oxygen. The Hgb then moves the oxygen to the plasma for transport to the tissues. The body’s demand for oxygen is affected by activity, metabolic status, temperature, and level of anxiety. The ability of Hgb to move the oxygen to the tissues depends on a number of factors, such as oxygen supply, ventilatory effectiveness, nutrition, cardiac output, hemoglobin level, smoking, drug use, and underlying disease. Any one of these factors can potentially impede the supply and transport of oxygen to the tissues.

Measurement of Oxygen in the Blood

The vast majority of oxygen carried in the blood is attached to hemoglobin and can be assessed by monitoring the oxygen saturation through pulse oximetry (SpO2).The target range for oxygen saturation as measured by blood analysis (SaO2), such as arterial blood gas, is 92% to 98% for a normal adult. Arterial blood gas (ABG) is the analysis of an arterial blood sample to evaluate the adequacy of ventilation, oxygen delivery to the tissues, and acid-base balance status and is measured as SaO2 (Simpson, 2004). For patients with COPD, the target SaO2 range is 88% to 92% (Alberta Health Services, 2015; O’Driscoll, Howard, & Davison, 2008; Kane et al., 2013). Only about 3% of the oxygen carried in the blood is dissolved in the plasma, which can be assessed by looking at the partial pressure of oxygen in the blood through blood gas analysis (PaO2). The normal PaO2 of a healthy adult is 80 to 100 mmHg. The SpO2 is more clinically significant than the PaO2 in determining the oxygen content of the blood.

Oxygen is considered a medication and therefore requires continuous monitoring of the dose, concentration, and side effects to ensure its safe and effective use (Alberta Health Services, 2015). Oxygen therapy may be indicated for hypoxemia and hypoxia.

Understanding Hypoxemia and Hypoxia

Although the terms hypoxemia and hypoxia are often used interchangeably, they do not mean the same thing. Hypoxemia is a condition where arterial oxygen tension or partial pressure of oxygen (PaO2) is below normal (<80 mmHg). Hypoxemia is the inadequate supply of oxygen in the arterial blood. Hypoxia is the reduction of oxygen supply at the tissue level, which is not measured directly by a laboratory value (Meštrović, 2014), but by pulse oximetry (SpO2) (O’Driscoll et al., 2008).

Generally, the presence of hypoxemia suggests that hypoxia exists. However, hypoxia may not be present in a patient with hypoxemia if the patient is able to compensate for a low PaO2 by increasing oxygen supply. This is usually achieved by increasing cardiac output (by raising the heart rate) or by decreasing tissue oxygen consumption. Conversely, patients who do not show signs of hypoxemia may be hypoxic if oxygen delivery to the tissues is diminished or if the tissues are unable to adequately use the oxygen.

Hypoxemia is the most common cause of tissue hypoxia, and if the correct diagnosis is made, it is readily treatable. Hypoxemia has a number of causes including:

Examples of medical conditions that have the potential to cause hypoxemia include:

With hypoxia, there is inadequate transport of oxygen to the cells or tissues, either because of obstruction, secretions, or tumours in the lungs; hypoventilation due to disease, injury to the respiratory system, or medications; or poor blood flow due to a compromised circulatory system (O’Driscoll et al., 2008). Hypoxia related to anemia or circulatory system compromise, such as decreased cardiac output, will respond poorly to oxygen therapy, and other appropriate interventions should be considered.

Oxygen Therapy Will:

It is important for the nurse to recognize early signs of respiratory compromise which might include shortness of breath, changes in mental status, anxiety, tachypnea (increase respiratory rate), and decreasing SpO2 despite increasing amounts of supplemental oxygen (Fournier, 2014). Hypoxia is a medical emergency (Alberta Health Services, 2015). Untreated hypoxia can result in anaerobic metabolism, acidosis, cell death, and organ failure (Considine, 2007). It is important for the nurse to build competence in recognizing hypoxia and to work within their scope of practice and agency policies and guidelines to provide treatment.

Critical Thinking Exercises

  1. Explain how you might know if your patient is hypoxic or hypoxemic?
  2. Why might a post-surgical patient require supplemental oxygen?

47

5.3 Pulse Oximetry

Oxygen saturation, sometimes referred to as ‘‘the fifth vital sign,” should be checked by pulse oximetry in all breathless and acutely ill patients (O’Driscoll et al., 2008). SpO2 and the inspired oxygen concentration should be recorded on the observation chart together with the oximetry result. The other vital signs of pulse, blood pressure, temperature, and respiratory rate should also be recorded in situations where supplemental oxygen is required.

Pulse oximetry is a painless, non-invasive method to monitor SpO2 intermittently and continuously. The use of a pulse oximeter is indicated in patients who have, or are at risk for, impaired gaseous exchange or an unstable oxygen status.

pulse oximeter
Pulse oximeter

The pulse oximeter is a probe with a light-emitting diode (LED) that is attached to the patient’s finger, forehead, or ear. Beams of red and infrared light are emitted from the LED, and the light wavelengths are absorbed differently by the oxygenated and the deoxygenated hemoglobin (Hgb) molecules. The receiving sensor measures the amount of light absorbed by the oxygenated and deoxygenated Hgb in the arterial (pulsatile) blood. The more Hgb that is saturated with oxygen, the higher the SpO2, which should normally measure above 95%.

Pulse oximeters have an indicator of signal strength (such as a bar graph, audible tone, waveform, or flashing light) to show how strong the receiving signal is. Measurements should be considered inaccurate if the signal strength is poor.

Pulse oximeters will also indicate heart rate by counting the number of pulsatile signals. To ensure accuracy, count the patient’s pulse rate by taking the pulse and comparing it to the pulse rate shown on the pulse oximeter.

Limitations

The most common cause of inaccuracy with pulse oximeters is motion artifact. Patient movement can cause pulsatile venous flow to be incorrectly measured as arterial pulsations, thus producing an inaccurate oximetry and pulse-rate reading.

Other causes for inaccuracy include some nail varnishes (nail polish), pigments (henna), bright lights (fluorescents), and poor peripheral perfusion. Poor peripheral perfusion can be caused by conditions such as hypothermia, peripheral vascular disease, vasoconstriction, hypotension, or peripheral edema (Perry et al., 2014; World Health Organization, 2011 ). A forehead probe can be used for patients with decreased peripheral perfusion.

Conditions such as jaundice, as well as intravascular dyes and carbon monoxide in the blood, can also influence oximetry readings. Anemic patients with low Hgb may have a normal SpO2 reading, even though the available oxygen is not enough to meet the metabolic demands of the body. Patients with elevated bilirubin concentrations may also have falsely low SpO2 readings (Howell, 2002).

Application of Pulse Oximetry

If measuring SpO2 by attaching the probe to a finger or toe, check the radial or pedal pulse and capillary refill of the finger or toe you plan to use. If the patient’s extremities are cold, you could try to warm his or her hands in yours, or apply warm towels to improve perfusion.

The patient’s finger or toe should be clean and dry. Check that the patient does not have artificial nails or nail polish, as both will influence the light transmission and should, therefore, be removed before applying pulse oximetry.

Check that the probe is positioned properly so that optical shunting (when light from the transmitter passes directly into the receiver without going through the finger) does not occur.

Bright ambient light may also affect the accuracy of pulse oximetry readings.

Hazards of Pulse Oximetry

Pulse oximetry is generally considered to be a safe procedure. However, tissue injury may occur at the measuring site as a result of probe misuse. Pressure sores or burns are possible effects of prolonged application (>2 hours). As such the nurse should consider anyone who is at risk of poor tissue integrity to be at risk  (elderly, cardiovascular disease,malnutrition).

Critical Thinking Exercises

  1. You are checking your patient’s SpO2 but the signal strength on the pulse oximeter is poor. What would be your next steps?
  2. Your patient has been admitted with a diagnosis of carbon monoxide poisoning with an SpOof 98%. What does this reading tell you?

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5.4 Signs and Symptoms of Hypoxia

Assessment for hypoxia can be done by completing a medical history, determining current medical condition, and performing a respiratory assessment. If a patient is experiencing any of the signs and symptoms listed in Table 5.2, hypoxia may be present.

Hypoxia must be treated immediately by the health care provider, as a lack of oxygen to tissues and organs can create serious complications (Alberta Health Services, 2015).

Table 5.2 Signs and Symptoms of Hypoxia

Safety considerations:
  • Presence of symptoms depends on the patient’s age, presence of disease process, level of health, and presence of chronic illness.
  • Consider any underlying causes of hypoxia, such as COPD, heart failure, anemia, and pneumonia, which need to be corrected to prevent and manage hypoxia (Perry et al., 2007).
  • Early signs of hypoxia are anxiety, confusion, and restlessness; if hypoxia is not corrected, hypotension will develop.
  • As hypoxia worsens, the patient’s vital signs, activity tolerance, and level of consciousness will decrease.
  • Late signs of hypoxia include bluish discoloration of the skin and mucous membranes, where vasoconstriction of the peripheral blood vessels or decreased hemoglobin causes cyanosis. Cyanosis is most easily seen around the lips and in the oral mucosa. Never assume the absence of cyanosis means adequate oxygenation.

Signs and Symptoms

Indications

 Tachypnea Increased respiration rate is an indication of respiratory distress.
 Dyspnea Shortness of breath (SOB) is an indication of respiratory distress.
Use of accessory muscles Use of neck or intercostal muscles when breathing is an indication of respiratory distress.
Noisy breathing Audible noises with breathing, or wheezes and crackles, are an indication of respiratory conditions. Assess lung sounds for adventitious sounds such as wheezing or crackles. Secretions can plug the airway, thereby decreasing the amount of oxygen available for gas exchange in the lung.
Decreased oxygen saturation levels Oxygen saturation levels should be between 92% and 98% for an adult without an underlying respiratory condition. Lower than 92% is considered hypoxic. For patients with COPD, oxygen saturation levels may range from 88% to 92%. Lower than 88% is considered hypoxic.
Flaring of nostrils or pursed lips Patients who are hypoxic may breathe differently, which may signal the need for supplemental oxygen.
Skin colour of patient Changes in skin colour to bluish or gray are a late sign of hypoxia.
Position of patient Patients in respiratory distress may voluntarily sit up or lean over by resting arms on their legs to enhance lung expansion. Patients who are hypoxic may not be able to lie flat in bed.
Ability of patient to speak in full sentences Patients in respiratory distress may be unable to speak in full sentences, or may need to catch their breath between sentences.
Change in mental status or loss of consciousness (LOC) This is a worsening and a late sign of hypoxia.
Restlessness or anxiety This is an early sign of hypoxia.
Data source: O’Driscoll et al., 2008; Perry et al., 2018

Critical Thinking Exercises

  1. Your patient is tachypneic and dyspneic. What is the first step you should take to ensure maximal lung expansion?
  2. Your patient is sitting up in high fowler’s position, but is still showing signs of hypoxia. What would be your best steps?

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5.5 Oxygen Therapy Systems

Tissue oxygenation is dependent on optimal or adequate delivery of oxygen to the tissues. Increasing the concentration of inhaled oxygen is an effective method of increasing the partial pressure of oxygen in the blood and correcting hypoxemia. Simply stated, oxygen therapy is a means to provide oxygen according to target saturation rates (as per physician orders or hospital protocol) to achieve normal or near normal oxygen saturation levels for acute and chronically ill patients (O’Driscoll et al., 2008). Those administering oxygen must monitor the patient to keep the saturation levels within the required target range. Oxygen should be reduced or discontinued in stable patients with satisfactory oxygen saturation levels (Perry et al., 2014).

Hypoxemia or hypoxia is a medical emergency and should be treated promptly. Failure to initiate oxygen therapy can result in serious harm to the patient. The essence of oxygen therapy is to provide oxygen according to target saturation rates, and to monitor the saturation rate to keep it within target range. The target range (SpO2) for a normal adult is 92% to 98%. For patients with COPD, the target SpO2 range is 88% to 92% (Alberta Health Services, 2015; Kane et al., 2013; O’Driscoll et al., 2008).

Although all medications given in the hospital require a prescription, oxygen therapy may be initiated without a physician order in emergency situations (BCCNP, 2019). Most hospitals will have a protocol in place to allow health care providers to apply oxygen in emergency situations. The health care provider administering oxygen is responsible for monitoring the patient response and keeping the oxygen saturation levels within the target range.

The most common reasons for initiating oxygen therapy include acute hypoxemia related to pneumonia, shock, asthma, heart failure, pulmonary embolus, myocardial infarction resulting in hypoxemia, post-operative states, pneumothorax, and abnormalities in the quality and quantity of hemoglobin. There are no contraindications to oxygen therapy if indications for therapy are present (Kane et al., 2013).

Oxygen Delivery Systems

There is a wide variety of devices available to provide oxygen support. Delivery systems are classified as low-flow or high-flow equipment, which provide an uncontrolled or controlled amount of supplemental oxygen to the patient (O’Driscoll et al., 2008). Selection should be based on preventing and treating hypoxemia and preventing complications of hyper-oxygenation. Factors such as how much oxygen is required, the presence of underlying respiratory disease, age, the environment (at home or in the hospital), the presence of an artificial airway, the need for humidity, a tolerance or a compliance problem, or a need for consistent and accurate oxygen must be considered to select the correct oxygen delivery device (O’Driscoll et al., 2008). Table 5.3 lists types of oxygen equipment.

Table 5.3 Types of Oxygen Equipment

Types of Oxygen Equipment

Additional Information

Nasal-cannula (low-flow system) Nasal cannula consists of a small bore tube connected to two short prongs that are inserted into the nares to supply oxygen directly from a flow meter or through humidified air to the patient. It is used for short- or long-term therapy (i.e., COPD patients), and is best used with stable patients who require low amounts of oxygen.

Advantages: Can provide 24% to 40% O2 (oxygen) concentration. Most common type of oxygen equipment. Can deliver O2 at 1 to 6 litres per minute (L/min). It is convenient as patient can talk and eat while receiving oxygen. May be drying to nares if level is above 4 L/min. Easy to use, low cost, and disposable.

Limitations: Easily dislodged, not as effective is a patient is a mouth breather or has blocked nostrils or a deviated septum or polyps. Nasal dryness can occur

Applying nasal prongs
Applying a nasal cannula
Nasal cannula
Nasal cannula
Simple face mask (low-flow system) A mask fits over the mouth and nose of the patient and consists of exhalation ports (holes on the side of the mask) through which the patient exhales CO2 (carbon dioxide). These holes should always remain open. The mask is held in place by an elastic around the back of the head, and it has a metal piece to shape over the nose to allow for a better mask fit for the patient. Humidified air may be attached if concentrations are drying for the patient.

Advantages: Can provide 40% to 60% O2 concentration. Flow meter should be set to deliver O2 at 6 to 10 L/min. Used to provide moderate oxygen concentrations. Efficiency depends on how well mask fits and the patient’s respiratory demands. Readily available on most hospital units. Provides higher oxygen for patients.

Disadvantages: Difficult to eat with mask on. Mask may be confining for some patients, who may feel claustrophobic with the mask on.

Note: exhalation ports / holes/ vents on the sides of the mask must be open to allow for gas exchange

Simple face mask
Non re-breather mask (high-flow system) Consists of a simple mask and a small reservoir bag attached to the oxygen tubing connecting to the flow meter. With a re-breather mask, there is no re-breathing of exhaled air. It has a series of one-way valves between the mask and the bag and the covers on the exhalation ports. On inspiration, the patient only breathes in from the reservoir bag; on exhalation, gases are prevented from flowing into the reservoir bag and are directed out through the exhalation ports.

Advantages: With a good fit, the mask can deliver between 60% and 80% FiO2 (fraction of inspired oxygen). The flow meter should be set to deliver O2 at 10 to 15 L/min. Flow rate must be high enough to ensure that the reservoir bag remains partially inflated during inspiration.

Figure 5.1 non rebreather mask

Disadvantages: These masks have a risk of suffocation if the gas flow is interrupted. The bag should never totally deflate. The patient should never be left alone unless the one-way valves on the exhalation ports are removed. This equipment is used by respiratory therapists for specific short-term, high oxygen requirements such as pre-intubation and patient transport. They are not available on general wards due to: 1. the risk of suffocation, 2. the chance of hyper-oxygenation, and 3. their possible lack of humidity. The mask also requires a tight seal and may be hot and confining for the patient. The mask will interfere with talking and eating.

Face tent (low-flow system) The mask covers the nose and mouth and does not create a seal around the nose.

Advantages: Can provide 28% to 100% O2 Flow meter should be set to deliver O2 at a minimum of 15 L/min. Face tents are used to provide a controlled concentration of oxygen and increase moisture for patients who have facial burn or a broken nose, or who are are claustrophobic.

Disadvantages: It is difficult to achieve high levels of oxygenation with this mask…but sometimes this is the only option

Face Tent
Face tent
Venturi mask (high-flow system) High-flow system consisting of a bottle of sterile water, corrugated tubing, a drainage bag, air/oxygen ratio nebulizer system, and a mask that works with the corrugated tubing. The mask may be an aerosol face mask, tracheostomy mask, a T-piece, or a face tent. The key is that the flow of oxygen exceeds the peak inspiratory flow rate of the patient, and there is little possibility for the patient to breathe in air from the room

Advantages: The system can provide 24% to 60% O2 at 4 to 12 L/min. Delivers a more precise level of oxygen by controlling the specific amounts of oxygen delivered. The port on the corrugated tubing (base of the mask) sets the oxygen concentration. Delivers humidified oxygen for patient comfort. It does not dry mucous memb