Clinical Procedures for Safer Patient Care by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.
© 2015 British Columbia Institute of Technology
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Clinical Procedures for Safer Patient Care was created by Glynda Reese Doyle and Jodie Anita McCutcheon and funded by BCcampus Open Education.
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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 practise in the classroom and laboratory, and then apply what they have learned to practise 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, interprofessional 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).
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 practised 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.
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 88 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 objectives, 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 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. Key terms are set in bold throughout the book and laid out again 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, we have used the term patient to refer to any person who is being cared for in the health care setting.
1. BC Patient Safety and Quality Council. This webstie 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.
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.
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
Special thanks to those without whom this book would not have been possible:
Thank you to Lauri Aesoph and your team at BCcampus for your patience and attention to detail with our writing and formatting of the content in this book. We are grateful for your time, effort, and expertise in the development and writing of the chapters. All your efforts helped us achieve our goal of preparing students for safer clinical practice. Thank you for going above and beyond to ensure a quality and timely production, and thank you for the many helpful comments along our journey.
Thank you to Doug Wiebe (Faculty, BSN program at BCIT) for his photographic expertise and willingness to be photographed. Thank you to Heather Clark (Faculty, BSN program at BCIT) for taking the time to make comments and suggestions, and to critique our chapter on wound care to make it a more useful and relevant tool for our students. Thank you to Kathy Rogers (graphic artist at BCIT) for her patience and attention to detail in recreating images to our satisfaction. We are grateful to Cynthia Kent (records and copyright manager at BCIT) for her attention to copyright and licensing. We would also like to thank Sandy del Vecchio (nursing lab technician at BCIT) for her patience in finding and organizing the equipment in our photographs, and her willingness to be the subject of a number of our photographs.
Finally, thank you to our families for their support, encouragement, and patience in our journey through writing this resource, and the unanticipated additional hours and hours of work.
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.
In health care, 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, health care 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 health care 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 Objectives
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 health care associated infections (HAIs) in all health care settings. HAIs, also known as nosocomial infections, are infections that occur in any health care setting as a result of contact with a pathogen that was not present at the time the person infected was admitted (World Health Organization[WHO], 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 health care 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, routine practices, a system of recommended IPAC practices, are to be used consistently with all patients at all times in all health care settings (Public Health Agency of Canada [PHAC], 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.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Complete a risk assessment to determine your need for PPE (gown, clean gloves, mask, face shield, or eyewear). | Consider: Will your face, hands, skin, mucous membranes, or clothing be exposed to blood, excretions, or secretions, either 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 health care workers, patients, and visitors. Health care 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 health care 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/signage for appropriate use and disposal of PPE for visitors, patients, and all health care 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 health care providers and patients. | ||
8. Use avoidance procedures/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 source: CDC, 2007, 2014; Perry et al., 2014; PIDAC, 2012; PHAC, 2012b, 2013 |
Critical Thinking Exercises
Hand hygiene is the most important part of practice for health care 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 health care, as outlined in Checklist 2 and illustrated in Figure 1.1.
Two types of hand hygiene are commonly used in the health care setting: hand hygiene with an alcohol-based hand rub (see Figure 1.2) and hand hygiene with soap and water.
Alcohol-based hand rub (ABHR) is a product containing 60% to 90% alcohol concentration and is recommended for hand hygiene in health care 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.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Remove all jewellery on hands. Apply 1 to 2 pumps of product into palm of dry hands. | 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 for the entire procedure of 20 to 30 seconds. Always follow the manufacturer’s guidelines. | ||
2. Rub hands together, palm to palm. | Rubbing hands together ensures palm surfaces are covered by the product. | ||
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. | ||
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. | ||
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. | ||
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. | ||
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. | ||
8. Hands are now safe to use. | |||
Data source: CDC, 2012; PIDAC, 2012; PHAC, 2012b; WHO, 2009a, 2009b |
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.
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 health care 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 non-sterile gloves.
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 health care 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
Certain pathogens and communicable diseases are easily transmitted and require additional precautions to interrupt the spread of suspected or identified agents to health care 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).
There are three categories of additional precautions: contact precautions, droplet precautions, and airborne precautions.
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), vancomycin-resistant Enterococci (VRE), 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).
Tables 1.1, 1.2, and 1.3. summarize the three categories of additional precautions.
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 |
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 |
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 |
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 health care 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.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Remove rings, bracelets, and watches. Perform hand hygiene. | This prepares hands for direct patient care. | ||
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. | ||
3. Apply surgical or N95 mask. 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 health care 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. Replace mask if it becomes wet or soiled. | ||
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. | ||
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. | ||
Data source: Barratt, Shaban, & Moyle, 2011; PIDAC, 2012; PHAC, 2012b |
See Checklist 7 for steps on how to doff or remove PPE.
Disclaimer: Always review and follow your hospital 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. 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. | Clean hands if they feel or look dirty. | ||
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. | ||
4. Perform hand hygiene. | Always perform hand hygiene after removing gown. Hands may have been contaminated upon removal of the gown. | ||
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. | ||
6. Remove mask/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. Dispose of the mask in the garbage bin. | ||
7. Perform hand hygiene. | This step reduces the transmission of microorganisms. | ||
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.
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.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
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. | 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
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 (BC Centre for Disease Control, 2010). 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 health care, 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. SSI is defined as an “infection that occurs after surgery in the area of surgery” (CDC, 2010, p. 2). Preventing and reducing SSI are the most important reasons for using sterile technique during invasive procedures and surgeries.
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 health care workers to speak up and protect all patients from infection. See Checklist 9 for the principles of sterile technique.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | 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. 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. | ||
7. 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. | ||
8. If there is any doubt about the sterility of an object, it is considered non-sterile. | Known sterility must be maintained throughout any procedure. | ||
9. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or items contact only non-sterile areas. | 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. | ||
10. 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 source: Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014 |
Critical Thinking Exercises
The operating room (OR) is a sterile, organized environment. As a health care 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.
There are specific requirements for all health care 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 10 for the specific steps to take before entering an 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 health care 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:
| 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 area is sterile/non-sterile will prevent accidental contamination of sterile fields and delays in surgery. Sterile persons/areaThe 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 person/areaA 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 source: Kennedy, 2013; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014 |
Critical Thinking Exercises
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.
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).
Surgical hand scrub techniques and supplies to clean hands will vary among health care agencies. Most protocols will 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 11 for the steps to follow when scrubbing with medicated soap.
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 health care 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 12.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Remove all jewellery. | Jewellery harbours more microorganisms than do hands. | ||
2. No artificial nails, extenders, or chipped nail polish should be worn. | Artificial nails, extenders, and chipped nail polish can harbour additional microorganisms. | ||
3. Inspect hands for sores and 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, 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. | ||
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. | ||
8. Open sterile packaging by peeling open the top seam and pulling down. | Open sterile packaging without contaminating inner package. | ||
9. Place inner package on 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. | ||
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. | ||
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. | ||
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. | ||
13. 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. | ||
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. | ||
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. | ||
Data source: ATI, 2015b; 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.
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 13 for the steps for preparing a sterile field.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
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. | ||
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. | ||
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. | ||
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. | ||
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. | ||
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. | ||
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. | ||
9. Add solution to the sterile tray by pouring the solution carefully into the receptacle:
| Do not touch the edge of the solution receptacle. Place the receptacle near the edge of 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 source: ATI, 2015c; Berman & Snyder, 2016; Kennedy, 2013; Perry et al., 2014; Rothrock, 2014 |
Wearing sterile surgical attire (sterile gowns, closed gloving, and masks) and PPE is essential to keep the restricted and semi-restricted areas clean and to minimize sources of microbial transmission and contamination. It is important to minimize the patient’s exposure to the surgical team’s skin, mucous membranes, and hair by the proper application of surgical attire. An extensive list of recommendations for surgical attire can be located on the Association of periOperative Registered Nurses (AORN) website at Recommendations for surgical attire (Braswell & Spruce, 2012).
Critical Thinking Exercises
Infection control and prevention practices are a critical component of patient safety in the health care environment. In order to protect the public and cut health care costs, all health care 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 health care risks such as health care-associated infections. If effectively applied, infection control and prevention practices will prevent and minimize transmission of infections in health care settings.
Key Takeaways
Accreditation Canada. (2013). Infection prevention and control. Mentum Quarterly, 5(4). Retrieved on Feb 28, 2015, 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 on Feb 28, 2015, from: http://www.aaaai.org/conditions-and-treatments/Library/At-a-Glance/Latex-Allergy.aspx
ATI. (2015a). Traditional hand scrub method. Retrieved from ATI Nursing Education. Surgical Asepsis. Retrieved on Oct 10, 2015, from http://atitesting.com/ati_next_gen/skillsmodules/content/surgical-asepsis/viewing/attire-tradscrub.html
ATI. (2015b). Open-gloving technique. Retrieved from ATI Nursing Education. Surgical Asepsis. Retrieved on Oct 10, 2015, from http://atitesting.com/ati_next_gen/skillsmodules/content/surgical-asepsis/viewing/glove-open.html
ATI. (2015c). Setting up a sterile field. Retrieved from ATI Nursing Education. Surgical Asepsis. Retrieved on Oct 10, 2015, from http://atitesting.com/ati_next_gen/skillsmodules/content/surgical-asepsis/equipment/field.html
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 on Feb 21, 2015, 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 on Nov 6, 2015 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, New Jersey: 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 on Oct 10, 2015, 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 on Feb 27, 2015, from http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html
Centers for Disease Control (CDC). (2014). Types of healthcare-associated infections. Retrieved on Feb 27, 2015, from http://www.cdc.gov/HAI/infectionTypes.html
Infection Control Today. (2000). Asepsis and aseptic practices in the operating room. Retrieved on Oct 10, 2015, 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. Retreived on Feb 27, 2015, 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 on Oct 10, 2015, from http://flex5114.weebly.com/uploads/1/4/5/1/14518934/ornac_standards.pdf
Patrick, M., & Van Wicklin, S. A. (2012). AORN recommended practice for hand hygiene. AORN Journal, 9(4), 492-507. doi; 10.1016/j.aorn.2012.01.019 492
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) (Ontario Agency for Health Provincial Infectious Disease Advisory Committee). (2012). Routine practices and additional precautions in all health care settings (3rd ed.). Toronto, ON: Queen’s Printer for Ontario. Retrieved on Feb 20, 2015, 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 on Feb 26, 2015, 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 on Feb 26, 2015, 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 on Feb 26, 2105, from http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/infections-eng.php#a8
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. Centers for Disease Control. Retrieved on Feb 17, 2015, from: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
World Health Organization (WHO). (2009a). WHO guidelines for hand hygiene in health care: First global patient safety challenge. Retrieved on Feb 6, 2015, from http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf?ua=1
World Health Organization (WHO). (2009b). Five moments for hand hygiene. Retrieved on March 1, 2015, from: http://www.who.int/gpsc/tools/Five_moments/en/
Systematic health assessments are performed regularly in nearly every health care setting. For example:
A routine physical assessment reveals information to supplement a patient’s database. The assessment is documented according to agency policy, and unusual findings are reported to appropriate members of the health care team. Ongoing, objective, and comprehensive assessments promote continuity in health care.
The ability to think critically and interpret patient behaviours and physiologic changes is essential. The skills of physical assessment are powerful tools for detecting both subtle and obvious changes in a patient’s health. 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).
Learning Objectives
“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968, cited in Rosdahl & Kowalski, 2007, p. 704). Pain is a subjective experience, and self-report of pain is the most reliable indicator of a patient’s experience. Determining pain is an important component of a physical assessment, and pain is sometimes referred to as the “fifth vital sign.”
Pain assessment is an ongoing process rather than a single event (see Figure 2.1). A more comprehensive and focused assessment should be performed when someone’s pain changes notably from previous findings, because sudden changes may indicate an underlying pathological process (Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014).
Always assess pain at the beginning of a physical health assessment to determine the patient’s comfort level and potential need for pain comfort measures. At any other time you think your patient is in pain, you can use the mnemonic LOTTAARP (location, onset, timing, type, associated symptoms, alleviating factors, radiation, precipitating event) to help you remember what questions to ask your patient. See Checklist 14 for the questions to ask and steps to take to assess pain.
Critical Thinking Exercises
Figure 2.1
Children’s pain scale by Robert Weis is used under a CC BY SA 4.0 licence.
Temperature, pulse, respiration, blood pressure (BP), and oxygen saturation, are measurements that indicate a person’s hemodynamic status. These are the five vital signs most frequently obtained by health care practitioners (Perry, Potter, & Ostendorf, 2014). Vital signs will potentially reveal sudden changes in a patient’s condition and will also measure changes that occur progressively over time. A difference between patients’ normal baseline vital signs and their present vital signs may indicate the need for intervention (Perry et al., 2014). Checklist 15 outlines the steps to take when checking vital signs.
Critical Thinking Exercises
The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care 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, but a health history may be taken whenever additional subjective information from the patient 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 signs and symptoms described by the patient but 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. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012).
The hospital will have a form with assessment questions similar to the ones listed in Checklist 16.
Critical Thinking Exercises
A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system.
A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |
Safety considerations:
| |
Steps | Additional Information |
1. General appearance:
| Alterations may reflect neurologic impairment, oral injury or impairment, improperly fitting dentures, differences in dialect or language, or potential mental illness. Unusual findings should be followed up with a focused neurological system assessment. |
This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9. 2. Skin, hair, and nails:
| Check for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions. Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes. Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure. Check hair for the presence of lice and/or nits (eggs), which are oval in shape and adhere to the hair shaft. |
3. Head and neck:
| Check eyes for drainage, pupil size, and reaction to light. Drainage may indicate infection, allergy, or injury. Slow pupillary reaction to light or unequal reactions bilaterally may indicate neurological impairment. Dry mucous membranes indicate decreased hydration. Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment. |
4. Chest:
| Chest expansion may be asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, or pneumothorax. Use of accessory muscles may indicate acute airway obstruction or massive atelectasis. Jugular distension of more than 3 cm above the sternal angle while the patient is at 45º may indicate cardiac failure. The presence of crackles or wheezing must be further assessed, documented, and reported. Unusual findings should be followed up with a focused respiratory assessment. Note the heart rate and rhythm, identify S1 and S2, and follow up on any unusual findings with a focused cardiovascular assessment. |
5. Abdomen:
| Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction. Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum. Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus. Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis. Unusual findings in urine output may indicate compromised urinary function. Follow up with a focused gastrointestinal and genitourinary assessment. Unusual findings with bowel movements should be followed up with a focused gastrointestinal and genitourinary assessment. |
6. Extremities:
| Limitation in range of movement may indicate articular disease or injury. Palpate pulses for symmetry in rate and rhythm. Asymmetry may indicate cardiovascular conditions or post-surgical complications. Unequal handgrip and/or foot strength may indicate underlying conditions, injury, or post-surgical complications. CWMS: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion. Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position. Palpate and inspect capillary refill and report if more than 3 seconds. To check capillary refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction. Unusual findings should be followed up with a focused cardiovascular assessment. Clubbing of nails, in which the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis. |
7. Back area (turn patient to side or ask to sit up or lean forward):
| Check for curvature or abnormalities in the spine. Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position. |
8. Tubes, drains, dressings, and IVs:
| Note amount, colour, and consistency of drainage (e.g., Foley catheter), or if infusing as prescribed (e.g., intravenous). Assess wounds for large amounts of drainage or for purulent drainage, and provide wound care as indicated. |
9. Mobility:
| Assess patient’s risk for falls. Document and follow up any indication of falls risk. Note use of mobility aids and ensure they are available to the patient on ambulation. |
10. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation and reporting promote patient safety. |
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012 |
Critical Thinking Exercises
The ABCCS assessment (airway, breathing, circulation, consciousness, safety) is the first assessment you will do when you meet your patient. This assessment is repeated whenever you suspect or recognize that your patient’s status has become, or is becoming, unstable.
For example, if you assess that your patient is short of breath (dyspneic) with an increased respiration rate (tachypneic), then you should proceed with an ABCCS assessment and a focused respiratory assessment with appropriate interventions.
The ABCCS assessment includes the steps in Checklist 18.
Critical Thinking Exercises
Health care professionals do focused assessments in response to a specific patient health problem recognized by the assessor as needing further assessment of a body system or systems.
A focused respiratory system assessment includes collecting subjective data about the patient’s history of smoking, collecting the patient’s and patient’s family’s history of pulmonary disease, and asking the patient about any signs and symptoms of pulmonary disease, such as cough and shortness of breath. Objective data is also assessed.
The focused respiratory system assessment in Checklist 19 outlines the process for gathering objective data.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Conduct a focused interview related to history of respiratory disease, smoking, and environmental exposures. | Ask relevant questions related to dyspnea, cough/sputum, fever, chills, chest pain with breathing, previous history, treatment, medications, etc. | ||
2. Inspect:
| Patients in respiratory distress may have an anxious expression, pursed lips, and/or nasal flaring. Asymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis. With hypoxemia, cyanosis of the extremities or around the mouth may be noted. | ||
3. Auscultate (anterior and posterior) lungs for breath sounds and adventitious sounds.
| Fine crackles (rales) may indicate asthma and chronic obstructive pulmonary disease (COPD). Coarse crackles may indicate pulmonary edema. Wheezing may indicate asthma, bronchitis, or emphysema. Low-pitched wheezing (rhonchi) may indicate pneumonia. Pleural friction rub (creaking) may indicate pleurisy. | ||
4. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013 |
The cardiovascular and peripheral vascular system affects the entire body. A cardiovascular and peripheral vascular system assessment includes collecting subjective data about the patient’s diet, nutrition, exercise, and stress levels; collecting the patient’s and the patient’s family’s history of cardiovascular disease; and asking the patient about any signs and symptoms of cardiovascular and peripheral vascular disease, such as peripheral edema, shortness of breath (dyspnea), and irregular pulse rate. Objective data is also assessed.
The focused cardiovascular and peripheral vascular system assessment in Checklist 20 outlines the process for gathering objective data.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Conduct a focused interview related to cardiovascular and peripheral vascular disease. | Ask relevant questions related to chest pain/shortness of breath (dyspnea), edema, cough, fatigue, cardiac risk factors, leg pain, skin changes, swelling in limbs, history of past illnesses, history of diabetes, injury. | ||
2. Inspect:
| Cyanosis is an indication of decreased perfusion and oxygenation. Alterations and bilateral inconsistencies in colour, warmth, movement, and sensation (CWMS) may indicate underlying conditions or injury. Sudden onset of intense, sharp muscle pain that increases with dorsiflexion of foot is an indication of deep venous thrombosis (DVT), as is increased warmth, redness, tenderness, and swelling in the calf. Note: DVT requires emergency referral because of the risk of developing a pulmonary embolism. | ||
3. Auscultate apical pulse for one minute. Note the rate and rhythm. | Note the heart rate and rhythm. Identify S1 and S2 and follow up on any unusual findings. | ||
4. Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses. | Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction. | ||
5. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013 |
The gastrointestinal and genitourinary system is responsible for the ingestion of food, the absorption of nutrients, and the elimination of waste products. A focused gastrointestinal and genitourinary assessment includes collecting subjective data about the patient’s diet and exercise levels, collecting the patient’s and the patient’s family’s history of gastrointestinal and genitourinary disease, and asking the patient about any signs and symptoms of gastrointestinal and genitourinary disease, such as abdominal pain, nausea, vomiting, bloating, constipation, diarrhea, and characteristics of urine and faeces. Objective data is also assessed.
The focused gastrointestinal and genitourinary assessment in Checklist 21 outlines the process for gathering objective data.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Position patient supine if tolerated | |||
Steps | Additional Information | ||
1. Conduct a focused interview related to gastrointestinal and genitourinary systems. | Ask relevant questions related to the abdomen, urine output, last bowel movement, flatus, any changes, diet, nausea, vomiting, diarrhea. | ||
2. Inspect:
| Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.
| ||
3. Auscultate abdomen for bowel sounds in all four quadrants before palpation. | Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileus. Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus. | ||
4. Palpate abdomen lightly in all four quadrants. | Palpate to detect presence of masses and distension of bowel and bladder. Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis. | ||
Note: If patient is wearing a brief, ensure it is clean and dry. Inspect skin underneath for signs of redness/rash/breakdown. | |||
Note: If patient has a Foley catheter, inspect bag for urine amount, colour, and clarity. Inspect skin at insertion site for redness/breakdown. | |||
5. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013 |
A focused musculoskeletal assessment includes collecting subjective data about the patient’s mobility and exercise level, collecting the patient’s and the patient’s family’s history of musculoskeletal conditions, and asking the patient about any signs and symptoms of musculoskeletal injury or conditions. Objective data is also assessed.
The focused musculoskeletal assessment in Checklist 22 outlines the process for gathering objective data.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check patient information prior to assessment:
| Determine patient’s activity as tolerated (AAT)/bed rest requirements. Determine if patient has non-weight-bearing, partial, or full weight-bearing status. Determine if patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby, or lift transfer. Check alertness, medications, pain. Ask if patient uses walker/cane/wheelchair/crutches. Consider non-slip socks/hip protectors/bed-chair alarm. | ||
2. Conduct a focused interview related to mobility and musculoskeletal system. | Ask relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level (e.g., arthritis, joint problems, medications, etc.). | ||
3. Inspect, palpate, and test muscle strength and range of motion:
Evaluate client’s ability to sit up before standing, and to stand before walking, and then assess walking ability. | Note strength of handgrip and foot strength for equality bilaterally. Note patient’s gait, balance, and presence of pain. | ||
4. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013 |
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 et al., 2012). A focused neurological assessment includes collecting subjective data about the patient’s history of head injury or dysfunction, collecting the patient’s and the patient’s family’s history of neurological disease, and asking the patient about signs and symptoms of neurological conditions, such as seizures, memory loss (amnesia), and visual disturbances. Objective data is also assessed.
The focused neurological assessment in Checklist 23 outlines the process for gathering objective data.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||||||||||||||||||||||||||||||||||||||
Safety considerations:
| |||||||||||||||||||||||||||||||||||||||
Steps | Additional Information | ||||||||||||||||||||||||||||||||||||||
1. Conduct a focused interview related to the neurological system. | Ask relevant questions related to past or recent history of head injury, neurological illness, or symptoms, confusion, headache, vertigo, seizures, recent injury or fall, weakness, numbness, tingling, difficulty swallowing (dysphagia) or speaking (dysphasia), and lack of coordination of body movements. | ||||||||||||||||||||||||||||||||||||||
2. Assess mental health status. | Assess mental status by observing the patient’s appearance, attitude, activity (behaviour), mood and affect, and asking questions similar to those outlined in this example of a mini-mental state examination (MMSE). | ||||||||||||||||||||||||||||||||||||||
3. Assess neurological function using the Glasgow Coma Scale (GCS):
|
| ||||||||||||||||||||||||||||||||||||||
4. Note patient’s LOC (level of consciousness, oriented x 3), general appearance, and behaviour. | Note hygiene, grooming, speech patterns, facial expressions. | ||||||||||||||||||||||||||||||||||||||
5. Assess pupils for size, equality, reaction to light (PERL), and consensual reaction to light. | Unequal pupils may indicate underlying neurological disease or injury. | ||||||||||||||||||||||||||||||||||||||
6. Assess motor strength and sensation.
| Unequal motor strength and unusual sensation may indicate underlying neurological disease or injury, such as stroke or head injury. | ||||||||||||||||||||||||||||||||||||||
7. Report and document assessment findings and related health problems according to agency policy. | Accurate and timely documentation and reporting promote patient safety. | ||||||||||||||||||||||||||||||||||||||
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Perry et al., 2014; Stephen et al., 2012; Wilson & Giddens, 2013 |
Critical Thinking Exercises
Figure 2.2
The respiratory system by LadyofHats is in the public domain.
Figure 2.3
Sectional anatomy of the heart by Blausen Medical Communications, Inc. is used under a CC BY 3.0 licence.
Figure 2.4
Digestive system diagram by Mariana Ruiz Villarreal is in the public domain.
Figure 2.5
Urinary system is in the public domain.
Figure 2.6
Anterior and posterior views of muscles by OpenStax College is used under a CC BY 3.0 licence.
Figure 2.7
Nervous system diagram by William Crochot is used under a CC BY SA 4.0 licence.
This chapter has outlined the different components of health assessment. Different assessments are done in different contexts and are dependent on the type of patient, health care professional, and environment.
The health assessment is an opportunity to develop a therapeutic relationship with the patient, optimize communication, promote health, and provide patient education as necessary. Throughout the assessment, be aware of ensuring patient safety, privacy, and dignity.
The assessment must always be documented according to the agency policy, and any unusual findings must be reported comprehensively, in conjunction with other pertinent findings, to appropriate members of the health care team.
Key Takeaways
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).
Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2014). Physical examination and health assessment. Toronto, ON: Elsevier-Saunders.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.
Rosdahl, C. B., & Kowalski, M. T. (2007). Textbook of basic nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
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.
In health care, all patient-handling activities, such as positioning, transfers, and ambulation, are considered high risk for injury to patients and health care providers. This chapter reviews the essential guidelines for proper body mechanics and safe transfer techniques to minimize and eliminate injury in health care.
Learning Objectives
Body mechanics involves 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 helps prevent injuries for patients and health care providers (Perry, Potter, & Ostendorf, 2014).
A musculoskeletal injury (MSI) is an injury or disorder of the muscles, tendons, ligaments, joints or nerves, blood vessels, or related soft tissue including a sprain, strain, or inflammation related to a work injury. MSIs are the most common health hazard for health care providers (WorkSafeBC, 2013). Table 3.1 lists risk factors that contribute to an MSI.
Factor | Special Information | ||
Ergonomic risk factors | Repetitive or sustained awkward postures, repetition, or forceful exertion | ||
Individual risk factors | Poor work practice; poor overall health (smoking, drinking alcohol, and obesity); poor rest and recovery; poor fitness, hydration, and nutrition | ||
Data source: Perry et al., 2014; Workers Compensation Board, 2001; WorkSafeBC, 2013 |
When health care providers are exposed to ergonomic risk factors, they become fatigued and risk musculoskeletal imbalance. Additional exposure related to individual risk factors puts health care providers at increased risk for an MSI (WorkSafeBC, 2013). Preventing an MSI 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.
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 increase. 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. A wide base of support 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. Diagram (B) demonstrates how balance is not maintained when the line of gravity falls outside the base of support, and diagram (C) shows how balance is regained when the line of gravity falls within the base of support.
Table 3.2 describes the principles of body mechanics that should be applied during all patient-handling activities.
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. Equilibrium is maintained as long as the line of gravity passes through its base of support. | ||
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. | ||
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. | ||
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 it is 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 source: Berman & Snyder, 2016; Perry et al., 2014; WorkSafeBC, 2013 |
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 (WorkSafeBC, 2006). Table 3.3 lists some assistive devices found in the hospital and community setting.
Type | Definition | ||
Gait belt or transfer belt | Used to ensure a good grip on unstable patients. The device provides more stability when transferring patients. It is a 2-inch-wide (5 mm) 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. | ||
Slider board or transfer board | A slider board is used to transfer immobile patients from one surface to another while the patient is lying supine. The board allows health care providers to safely move immobile, bariatric, or complex patients. | ||
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. | ||
Data source: Perry et al., 2014; WorkSafeBC, 2006 |
Critical Thinking Exercises
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 what to assess and how to assess a patient prior to positioning, ambulation, and transfers.
To help you assess and make decisions about moving a patient, refer to these two useful tools.
Critical Thinking Exercises
When patients are recovering from illness, they may require assistance to move around in bed, to transfer from bed to wheelchair, or to ambulate. Changing patient positions in bed and mobilization are also vital to prevent contractures from immobility, maintain muscle strength, prevent pressure ulcers, and help body systems function properly for optimal health and healing (Perry et al., 2014). 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., 2014).
At times, patients are assessed and given a “level of assistance” required for transferring. This is most common in residential care settings. The level of assistance is based on the patient’s ability to transfer and stand. The terms describing different levels of assistance are used by health care providers to communicate with each other so everyone understands what type of assistance is required. The assistance needed is usually charted on the patient’s Kardex, above the head of the bed, and/or on the patient’s chart. Table 3.4 describes different types of assistance in the hospital and community setting.
Level of Assistance | Description | ||
Independent | The patient is able to transfer independently and safely. | ||
Standby supervision | The patient requires no physical assistance but may require verbal reminder. This type of patient may also be learning to transfer independently using a wheelchair, walker, or cane. | ||
Minimal assist | The patient is cooperative but needs minimal physical assistance with the transfer. | ||
One-person standing pivot | The patient can bear weight on one or both legs and is cooperative and predictable. The patient also can sit with minimal support on the side of the bed. | ||
Two-person standing pivot | The patient can assist with weight bearing, but may be inconsistent. The patient is cooperative and predictable. | ||
One-person assist with transfer board | The patient is cooperative, follows directions, and has good trunk control. The patient can use their arms, but cannot bear weight on both legs. | ||
Two-person assist with transfer board | The patient is cooperative and can follow directions. The patient can use their arms, but cannot bear weight on both legs. The patient does not have good trunk control. The patient’s wheelchair has removable arms. | ||
Mechanical stand | The patient may have some ability to stand, but is unreliable. The patient may be unpredictable (due to cognitive changes, medications). The patient is a heavy two-person transfer and requires toileting or pericare. The patient does not have severe limb contractures or injuries where movement is medically contraindicated (e.g., spinal injury). | ||
Data source: Winnipeg Regional Health Authority (WRHA), 2008 |
If the patient is cooperative, able to bear weight, and has some balance to sit (see Checklist 24: Risk Assessment), the health care provider must decide how much assistance the patient needs. Table 3.5 provides guidelines to consider.
Assess | Description | ||
Minimal | One-person transfer with gait belt The patient is able to perform 75% of the required activity on their own. | ||
Moderate | Two-person transfer with a gait belt, a stander, or a two-person transfer with a slide board and a gait belt The patient is able to perform 50% of the required activity on their own. | ||
Maximum | Stander or a two-person transfer with a slide board and gait belt The patient is able to perform 25% of the required activity on their own. | ||
Data source: WRHA, 2008 |
Critical Thinking Exercises
Positioning a patient in bed is important for maintaining alignment and for preventing bed sores (pressure ulcers), foot drop, and contractures (Perry et al., 2014). Proper positioning is also vital for providing comfort for patients who are bedridden or have decreased mobility related to a medical condition or treatment. When positioning a patient in bed, supportive devices such as pillows, rolls, and blankets, along with repositioning, can aid in providing comfort and safety (Perry et al., 2014).
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 3.6 lists patient positions in bed.
Position | Description | ||
Supine position | Patient lies flat on back. Additional supportive devices may be added for comfort. | ||
Prone position | Patient lies on stomach with head turned to the side. | ||
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. | ||
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. | ||
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. | ||
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. | ||
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. | ||
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. | ||
Data source: ATI, 2015a; Perry et al., 2014; Potter et al., 2011 |
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 25 for the steps to move a patient up in bed.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Make sure an additional health care provider is available to help with the move. | This procedure requires two health care 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 health care provider. | ||
4. Raise bed to safe working height and ensure that brakes are applied. Health care providers stand on each side of the bed. | Principles of proper body mechanics help prevent MSI. Safe working height is at waist level for the shortest health care provider. | ||
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, 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 health care providers. | ||
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. | ||
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. | ||
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. | ||
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. Hand hygiene reduces the spread of microorganisms. | ||
Data source: Perry et al., 2014; PHSA, 2010 |
Watch these three videos for more information about how to move a patient up in bed.
Prior to ambulating, repositioning, 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 health care provider. Positioning the patient to the side of the bed also allows the health care provider to have the patient as close as possible to the health care provider’s centre of gravity for optimal balance during patient handling. Checklist 26 describes how to safely move a patient to the side of the bed.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Make sure you have as many additional health care providers as needed to help with the move. | The procedure works best with two or more health care providers, depending on the size of the patient and the size of the health care professional. | ||
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 for the shortest health care 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 health care providers. | ||
5. Fan-fold the draw sheet toward the patient with palms facing up. | |||
6. Have the health care 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. | ||
7. Have patient place arms across chest. | This step prevents injury to patient. | ||
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. | 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. | ||
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. Hand hygiene reduces the spread of microorganisms. | ||
Data source: Perry et al., 2014; PHSA, 2010 |
Critical Thinking Exercises
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 improved emotional and social well-being (Kalisch et al., 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.
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, Perry, Ross-Kerr, & Wood, 2010). 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 27 outlines the steps to positioning the patient on the side of a bed prior to ambulation (Perry, et al., 2014).
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check physician’s order to ambulate and supplies for ambulation if required, and perform an assessment of patient’s strength and abilities. Check physician orders for any restrictions related to ambulation due to medical treatment or surgical procedure. | Supplies (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. | This step prepares the patient to be moved. | ||
6. Place one hand behind patient’s shoulders, supporting the neck and vertebrae. | This provides support for the patient. | ||
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. | ||
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 health care provider. | ||
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 source: ATI, 2015b; Interior Health, 2013; Perry et al., 2014; PHSA, 2010 |
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, determine if assistance from additional health care providers or assistive devices is required. Checklist 28 reviews the steps to ambulating a patient with and without a gait belt.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
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. Proper footwear is non-slip or slip resistant footwear. Socks are not considered proper footwear. Check physician’s orders for any activity restrictions related to treatment or surgical procedures. | Proper footwear is essential to prevent accidental falls. | ||
2. Apply gait belt snugly around the patient’s waist if required. | Gait belts are applied over clothing. | ||
3. Assist patient by standing in front of the patient, grasping each side of the gait belt, keeping back straight and knees bent. | 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. | ||
4. While holding the belt, gently rock back and forth three times. On the third time, pull patient into a standing position. | This action provides momentum to help patient into 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. If the patient does not require a gait belt, place hand closest to the patient around the upper arm and hold the patient’s hand with your other hand. | Standing to the side of the patient provides assistance without blocking the patient. | ||
6. Before stepping away from the bed, 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. | Always perform a risk assessment prior to ambulation. Walk only as far as the patient can tolerate without feeling dizzy or weak. Ask patient how they feel during ambulation. | ||
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. | ||
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. | ||
9. When patient returns to 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. Hand hygiene reduces the spread of microorganisms. | ||
10. Document patient’s ability to tolerate ambulation and type of assistance required. | This provides a baseline of patient’s abilities and promotes clear communication between health care providers. | ||
Data source: ATI, 2015b; Interior Health, 2013; Perry et al., 2014; PHSA, 2010 |
Critical Thinking Exercises
Transfers are defined as moving a patient from one flat surface to another, such as from a bed to a stretcher (Perry et al., 2014). Types of hospital transfers include bed to stretcher, bed to wheelchair, wheelchair to chair, and wheelchair to toilet, and vice versa.
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 health care providers. Patients who require this type of transfer are generally immobile or acutely ill and may be unable to assist with the transfer. Checklist 29 shows the steps for moving patients laterally from one surface to another.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Always predetermine the number of staff required to safely transfer a patient horizontally. | Three to four health care providers are required for the transfer. | ||
2. Explain what will happen and how the patient can help (tuck chin in, keep hands on chest). Collect supplies. | This step provides the patient with an opportunity to ask questions and help with the transfer. | ||
3. Raise bed to safe working height. Lower 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 for the shortest health care provider. The patient must be positioned correctly prior to the transfer to avoid straining and reaching. May need additional health care providers to move patient to the side of the bed. | ||
4. Roll patient over and place slider board halfway under the patient, forming a bridge between the bed and the stretcher. Place sheet on top of the slider board. The sheet is used to slide patient over to the stretcher. The patient is returned to the supine position. Patient’s feet are positioned on the slider board. | The slider board must be positioned as a bridge between both surfaces. The sheet must be between the patient and the slider board to decrease friction between patient and board. Ensure all tubes and attachments are out of the way. | ||
5. Position stretcher beside the bed on the side closest to the patient, with stretcher slightly lower. Apply brakes. Two health care providers climb onto the stretcher and grasp the sheet. The lead person is at the head of the bed and will grasp the pillow and sheet. The other health care provider is positioned on the far side of the bed, between the chest and hips of the patient, and will grasp the sheet with palms facing up. The two caregivers on the stretcher grasp the draw sheet using a palms up technique, sitting up tall, and keeping their elbows close to their body and backs straight. | The position of the health care providers keeps the heaviest part of the patient near the health care providers’ centre of gravity for stability. | ||
6. The caregiver on the other side of the bed places his or her hands under the patient’s hip and shoulder area with forearms resting on bed. |
| ||
7. The designated leader will count 1, 2, 3, and start the move. The person on the far side of the bed will push patient just to arm’s length using a back-to-front weight shift. At the same time, the two caregivers 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 health care 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. The two caregivers will climb off the stretcher and stand at the side and grasp the sheet, keeping elbows tucked in. One of the two caregivers should be in line with the patient’s shoulders and the other should be at the hip area. On the count of three, with back straight and knees bent, the two caregivers 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 health care providers. | ||
9. At the same time, the caregiver on the other side slides 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 and lock brakes, raise side rails as required, and ensure call bell is within reach. | 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. Hand hygiene reduces the spread of microorganisms. | ||
Data source: ATI, 2015c; Perry et al., 2014; PHSA, 2010 |
Patients often need assistance when moving from a bed to a wheelchair. A patient must be cooperative and predictable, 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 30 for the steps to transfer a patient from the bed to the wheelchair (PHSA, 2010).
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. One health care provider is required. | The patient should be assessed as a 1-person assist. | ||
2. Perform hand hygiene. Explain what will happen during the transfer and how the patient can help. Apply proper footwear prior to ambulation | This step provides the patient with an opportunity to ask questions and help with the positioning. | ||
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 strong side. | Ensure brakes are applied on the wheelchair. | ||
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 health care provider’s feet. | ||
5. As the patient leans forward, grasp the gait belt (if required) on the side 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. | |||
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. | |||
7. Once standing, have the patient take a few steps 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. | ||
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 health care providers. | ||
Data source: ATI, 2015b; Perry et al., 2014; PHSA, 2010 |
Critical Thinking Exercises
Patient falls are the most reported patient safety events in British Columbia and account for 40% of all adverse events (BCPSLS, 2015). Falls are a major priority in health care, and health care providers are responsible for identifying, managing, and eliminating potential hazards to patients. All patient-handling activities (positioning, transfers, and ambulation) pose a risk to patients and health care providers. 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, Shever, Kanak, Picone, & Qin, 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 increase a patient’s risk for falls (Hook & Winchel, 2006).
All clients should be assessed for risk factors, and necessary prevention measures should be implemented as per agency policy. Table 3.7 lists factors that affect patient safety and general measures to prevent falls in health care.
Prior to ambulation consider the following risk factors:
| |||
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. | ||
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. | ||
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 source: Accreditation Canada, 2014; Canadian Patient Safety Institute, 2015; Perry et al., 2014; Titler et al., 2011 |
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 31 lists the steps to assisting a patient to the floor to minimize injury to patient and health care provider (PHSA, 2010).
Critical Thinking Exercises
To use the principles of body mechanics effectively and safely, health care 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
Accreditation Canada. (2014). From evidence to improvement in Canadian healthcare. Retrieved on Oct 10, 2015, from https://www.accreditation.ca/sites/default/files/falls-joint-report-2014-en.pdf
ATI. (2015a). Positioning. In ATI Nursing Education. Ambulation, transferring and range of motion. Retrieved on Oct 10, 2015, from http://www.atitesting.com/ati_next_gen/skillsmodules/content/ambulation/equipment/positioning.html
ATI. (2015b) Transferring – lying to sitting to standing. In ATI Nursing Education. Ambulation, transferring and range of motion. Retrieved on Oct 10, 2015, from http://www.atitesting.com/ati_next_gen/skillsmodules/content/ambulation/viewing/Transfering-lying-sit.html
ATI. (2015c). Transfer – bed to gurney. Retrieved from ATI Nursing Education. Ambulation, transferring and range of motion. Retrieved on Oct 10, 2015, from http://www.atitesting.com/ati_next_gen/skillsmodules/content/ambulation/viewing/Transfering-bed-gurney.html
Berman, A., & Snyder, S. J. (2016). Skills in clinical nursing (8th ed.). Upper Saddle River, New Jersey: Pearson.
British Columbia Patient Safety Learning System. (2015). Retrieved on April 25, 2015, from http://bcpslscentral.ca/
Canadian Patient Safety Institute. (2015). Reducing falls and injury from falls: Starter kit. Retrieved on Oct 10, 2015, from http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Getting%20Started%20Kit.pdf
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 on April 2, 2015, 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
Hook, M. L., & Winchel, S. (2006). Fall related injuries in acute care: Reducing the risk of harm. Clinical Practice, 15(6), 370-377.
Interior Health. (2012). Point of care risk assessment (Developed provincially). Retrieved on Oct 10, 2015, 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 on Oct 10, 2015, 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. doi: 10.1111/jocn.12315
National Institute for Occupational Safety and Health (NIOSH). (2010). Safe patient handling training for schools of nursing. Retrieved on Oct 10, 2015, from http://www.cdc.gov/niosh/docs/2009-127/pdfs/2009-127.pdf
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical nursing skills and techniques. St Louis, MO: Mosby Elsevier.
Potter, P. A., Perry, A. G., Ross-Kerr, J. C., & Wood, M. J. (2010). Canadian fundamentals of nursing (4th ed.). St Louis, MO: Mosby Elsevier.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2011). Basic nursing (7th Ed.). St Louis, MO: Mosby Elsevier.
Provincial Health Services Authority. (2010). Employee wellness elearning courses: Safe patient handling. Retrieved on April 2, 2015, from http://learn.phsa.ca/phsa/patienthandling/
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.
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. doi: 10.1891/1541-6577.25.2.127
Winnipeg Regional Health Authority. (2008). Safe patient handling and movement guidelines. Retrieved on April 2, 2015, from http://www.wrha.mb.ca/professionals/safety/files/Manual.pdf
Workers Compensation Board (WCB). (2001).Understanding the risks of musculoskeletal injury (MSI). An educational guide for workers on sprains, strains and other MSIs. Retrieved on Oct 10, 2015, from http://www.worksafebc.com/publications/Health_and_Safety/by_topic/assets/pdf/msi_workers.pdf
WorkSafeBC. (2006). Transfer assist devices for safer handling of patients. Retrieved on April 2, 2015, from http://www.worksafebc.com/publications/high_resolution_publications/assets/pdf/BK103.pdf
WorkSafeBC. (2010). Patient handling. Retrieved on Oct 10, 2015, from https://www2.worksafebc.com/PDFs/healthcare/patient_handling_bulletins_ALL.pdf
WorkSafeBC. (2013). Preventing musculoskeletal injury (MSI). Retrieved on April 2, 2015, from http://www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/msi_employers.pdf
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 Objectives
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, Potter, & Ostendorf, 2014).
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.
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:
| ||
Maturation (remodelling) phase | Collagen continues to strengthen the wound, and the wound becomes a scar. | ||
Data source: British Columbia Provincial Nursing Skin and Wound Committee, 2011; Perry et al., 2014 |
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.
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. 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. Pedal 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 ulcer | Also known as a pressure sore or decubiti wound, the pressure ulcer is 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 source: British Columbia Provincial Nursing Skin and Wound Committee, 2011, 2014; Perry et al., 2014 |
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.
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. | ||
Data source: Gallagher-Camden, 2012; Perry et al., 2014; Stotts, 2012 |
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.
Checklist 32 outlines the steps to take when assessing a wound.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Steps | 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:
| ||
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 using LOTTAARP. | ||
Data source: British Columbia Provincial Nursing Skin and Wound Committee, 2014; Perry et al., 2014 |
Critical Thinking Exercises
Figure 4.1
Phases of wound healing by Mikael Häggström is in the public domain.
The health care 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.
For more complex wounds with delayed healing, antiseptic solutions such as povidone iodine or chlorhexidene may be used for cleansing based on agency policy and the recommendation of a wound clinician or physician.
Checklist 33 outlines the steps for performing a simple dressing change.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check present dressing with non-sterile gloves. | Use non-sterile gloves to protect yourself from contamination. | ||
2. Perform hand hygiene. | Hand hygiene prevents spread of microorganisms. | ||
3. Gather necessary equipment. | Dressing supplies must be for single patient use only. Use the smallest size of dressing for the wound. Take only the dressing supplies needed for the dressing change to the bedside. | ||
4. Prepare environment, position patient, adjust height of bed, 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. | ||
6. Prepare sterile field. | |||
7. Add necessary sterile supplies. | |||
8. Pour cleansing solution. | Normal saline or sterile water containers must be used for only one client and must be dated and discarded within at least 24 hours of being opened. | ||
9. Prepare patient and expose dressed wound. | |||
10. Apply non-sterile gloves. | Use non-sterile gloves to protect yourself from contamination. | ||
11. Remove outer dressing with non-sterile gloves and discard as per agency policy. | |||
12. Remove inner dressing with transfer forceps, if necessary. | |||
13. Discard transfer forceps and non-sterile gloves according to agency policy. | |||
14. Assess wound. | |||
15. Drape patient with water-resistant underpad (optional). | Water-resistant underpad protects patient’s clothing and linen. | ||
16. Apply non-sterile gloves (optional). | Use non-sterile gloves to protect yourself from contamination. | ||
17. Cleanse wound using one 2 x 2 gauze per stroke. Strokes should be:
| The suture line is considered the “least contaminated” area and is cleansed first. | ||
18. Cleanse around drain (if present). | If a drain is present, clean the drain site using a circular stroke, starting with the area immediately next to the drain. Using a new swab, cleanse immediately next to the drain and attempt to clean a little further out from the drain. Continue this process with subsequent swabs until the skin surrounding the drain is cleaned. | ||
19. Apply inner dressing (4 x 4 gauze) with forceps to incision, then drain site (drain sponges/cut gauze). | |||
20. Discard non-sterile gloves if they were used. | This step prevents the spread of microorganisms. | ||
21. Apply outer dressing, keeping the inside of the sterile dressing touching the wound. | This step protects wound from contamination. | ||
22. To complete dressing change:
| Taking these step ensures the patient’s continued safety. | ||
23. Document procedure and findings according to agency policy. | Record dressing change as per hospital policy. Document the wound appearance, if the staples are intact, if the incision is well-approximated. Chart the time, place of wound, size, drainage and amount, type of cleaning solution, and dressing applied. State how the patient tolerated the procedure. Report any unusual findings or concerns to the appropriate health care professional. | ||
24. Compare wound to previous wound assessment and determine healing progress, if any. | If there is no movement toward healing, or if there is deterioration, notify the physician or wound care nurse according to agency policy. | ||
Data source: BCIT, 2010a; Perry et al., 2014 |
Critical Thinking Exercises
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 three types of sutures techniques: intermittent, blanket, and continuous (see Figure 4.2). The most commonly seen suture is the intermittent suture.
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 health care 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 health care 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 health care 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 34 provides the steps for intermittent suture removal.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Confirm physician/nurse practitioner (NP) orders, 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. | You will need sterile suture scissors or suture blade, sterile dressing tray (to clean incision site prior to suture removal), non-sterile gloves, normal saline, Steri-Strips, and sterile outer dressing. | ||
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. | ||
5. Prepare the sterile field and add necessary supplies in an organized manner. | This allows easy access to required supplies for the procedure. | ||
6. Remove dressing and inspect the wound using non-sterile gloves. | 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 health care provider. | ||
7. Remove non-sterile gloves and perform hand hygiene. | This prevents the transmission of microorganisms. | ||
8. Apply clean non-sterile gloves. | This prevents the transmission of microorganisms. | ||
9. Clean incision site according to agency policy. | This step reduces 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. | ||
10. To remove intermittent sutures, hold scissors in dominant hand and forceps in non-dominant hand. | This allows for dexterity with suture removal. | ||
11. Place a sterile 2 x 2 gauze close to the incision site. | The sterile 2 x 2 gauze is a place to collect the removed suture pieces. | ||
12. Grasp knot of suture with forceps and gently pull up knot while slipping the tip of the scissors under suture near the skin. Examine the knot. | |||
13. Cut under the knot as close as possible to the skin at the distal end of the knot.
| Never snip both ends of the knot as there will be no way to remove the suture from below the surface. Do not pull the contaminated suture (suture on top of the skin) through tissue. If using a blade to cut the suture, point the blade away from you and your patient. | ||
14. Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place cut knot on sterile 2 x 2 gauze. | |||
15. 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 removing sutures, apply Steri-Strips (using tensions to pull wound edges together), and notify appropriate health care providers. | |||
16. Using the principles of sterile technique, place Steri-Strips on location of every removed suture along incision line. | |||
17. Cut Steri-Strips so that they extend 1.5 to 2 inches on each side of incision. | Steri-Strips support wound tension across wound and help to eliminate scarring. | ||
18. Remove remaining sutures on incision line if indicated.
| Only remove remaining sutures if wound is well approximated. | ||
19. Place Steri-Strips on remaining areas of each removed suture along incision line. | The Steri-Strips will help keep the skin edges together. | ||
Data source: BCIT, 2010c; Perry et al., 2014 |
Checklist 35 outlines the steps to remove continuous and blanket stitch sutures.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Confirm physician/NP orders, 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. | You will need sterile suture scissors or suture blade, sterile dressing tray (to clean incision site prior to suture removal), non-sterile gloves, normal saline, Steri-Strips, and sterile outer dressing. | ||
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. | ||
5. Prepare the sterile field and add necessary supplies in an organized manner. | This step allows for easy access to required supplies for the procedure. | ||
6. Remove dressing and inspect the wound using non-sterile gloves. | 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 health care provider. | ||
7. Remove non-sterile gloves and perform hand hygiene. | This step prevents the transmission of microorganisms. | ||
8. Apply clean non-sterile gloves. | This prevents the transmission of microorganisms. | ||
9. Clean 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. | ||
10. Place sterile gauze close to suture line; grasp scissors in dominant hand and forceps in non-dominant hand. | This allows for dexterity with suture removal. | ||
11. Snip first suture close to the skin surface, distal to the knot. |
| ||
12. Snip second suture on the same side. | This action prevents the suture from being left under the skin. | ||
13. Grasp knotted end and gently pull out suture; place suture on sterile gauze. | |||
14. 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 notify physician. | |||
15. Apply Steri-Strips to suture line, then apply sterile dressing or leave open to air. | This step reduces the risk of infection. | ||
16. Position patient and lower bed to safe height; ensure patient is comfortable and free from pain. | This ensures patient safety. | ||
17. Complete patient teaching regarding Steri-Strips and bathing, wound inspection for separation of wound edges, and ways to enhance wound healing. | Instruct patient to take showers rather than bathe. Instruct patient to pat dry, and to not scrub or rub the incision. Instruct patient not to pull off Steri-Strips. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to three weeks). Instruct patient about the importance of not straining during defecation, and the importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing. | ||
18. Discard supplies according to agency policies for sharp disposal and biohazard waste. | Scissors and forceps may be disposed of or sent for sterilization. | ||
19. Perform hand hygiene. | Hand hygiene reduces risk of infection. | ||
20. Document procedures and findings according to agency policy. | Report any unusual findings or concerns to the appropriate health care professional. | ||
Data source: BCIT, 2010c; Perry et al., 2014 |
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 4.4. lists additional complications related to wounds closed with sutures.
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. Notify physician. | ||
Patient experiences pain when sutures are removed | Allow small breaks during removal of sutures. 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 health care 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 source: BCIT, 2010c; Perry et al., 2014 |
Critical Thinking Exercises
Staples are made of stainless steel wire and provide strength for wound closure. The wound location sometimes restricts their use because the staples must be far enough away from organs and structures. The aesthetic outcome may not be as desirable as a suture line, but staples are strong, quick to insert, and simple to remove.
Removal of staples requires sterile technique and a staple extractor. An order to remove the staples, and any specific directions for removal, must be obtained prior to the procedure. The health care 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 36 outlines the steps for removing staples from a wound.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Confirm physician 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. | Gather sterile staple extractors, sterile dressing tray, non-sterile gloves, normal saline, Steri-Strips, and sterile outer dressing. | ||
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. | ||
5. Prepare the sterile field and add necessary supplies (staple extractor). | This step allows easy access to required supplies for the procedure. | ||
6. Remove dressing and inspect the wound. | Visually assess the wound for uniform closure of the edges, absence of drainage, redness, and inflammation. 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 health care provider. | ||
7. Apply non-sterile gloves. | This reduces the risk of contamination. | ||
8. Clean incision site according to agency policy. | This 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 staples and wound bed. | ||
To Remove Staples (start with every second staple). | |||
9. 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, then 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. | ||
10. When both ends of the staple are visible, move the staple extractor away from the skin and place the staple on a sterile piece of gauze 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. | ||
11. 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. | ||
12. Using the principles of sterile technique, place Steri-Strips on location of every removed staple along incision line. | Cut Steri-Strips to allow them to extend 1.5 to 2 cm on each side of incision. Remove sterile backing to apply Steri-Strips. Steri-Strips support wound tension across wound and eliminate scarring. This allows wound to heal by primary intention. | ||
13. Remove remaining staples, followed by applying Steri-Strips along the incision line. | Steri-Strips support wound tension across wound and eliminate scarring. | ||
14. 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. | ||
15. 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. | ||
16. Complete patient teaching regarding Steri-Strips and bathing, wound inspection for separation of wound edges, and ways to enhance wound healing. | Instruct patient to take showers rather than bathe. Instruct patient not to pull off Steri-Strips and to allow them to fall off naturally and gradually (usually takes one to three weeks). Instruct on the importance of not straining during defecation, and of adequate rest, fluids, nutrition, and ambulation for optional wound healing. | ||
17. Discard supplies according to agency policies for sharp disposal and biohazard waste. | Staple extractor may be disposed of or sent for sterilization. | ||
18. Perform hand hygiene and document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate health care professional. | Hand hygiene reduces the risk of infection. | ||
Data source: BCIT, 2010c; Perry et al., 2014 |
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 4.5 lists other complications of removing staples.
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. Provide opportunity for the patient to deep breathe and relax during the procedure. | ||
Data source: BCIT, 2010c; Perry et al., 2014 |
Critical Thinking Exercises
A moist to dry dressing is a primary dressing that directly touches the wound bed, with a secondary dressing that covers the primary dressing. The type of wound dressing used depends not only on the characteristics of the wound but also on the goal of the wound treatment.
Important: Ensure pain is well managed prior to a dressing change to maximize patient comfort.
Checklist 37 outlines the steps for performing a moist to dry dressing change.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check present dressing using non-sterile gloves. | This provides an opportunity to collect required supplies for the procedure. | ||
2. Perform hand hygiene. | Hand hygiene reduces the risk of infection. | ||
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. | This helps prepare patient and bedside for procedure. | ||
5. Perform hand hygiene. | Hand hygiene reduces the risk of infection. | ||
6. Prepare sterile field. | |||
7. Add necessary sterile supplies. | |||
8. Pour cleansing solution. | |||
9. Expose dressed wound. | Inspect wound for the amount of drainage, odours, and type of drainage. | ||
10. 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 dissemination to the environment and of germ transmission from you to the patient and vice versa, as well as from one patient to another. | ||
11. Remove outer dressing with non-sterile gloves. | |||
12. Remove inner dressing with transfer forceps. | |||
13. Discard transfer forceps and non-sterile gloves. | |||
14. Drape patient with underpad (optional). | |||
15. Apply non-sterile gloves (optional). | This reduces the risk of infection. | ||
16. Place sterile or non-woven gauze in container of prescribed solution, and wring out excess solution. | Use enough prescribed solution to saturate gauze. Excess solution has the potential to contaminate surrounding areas. | ||
17. Apply moist gauze as a single layer onto wound surface, pack gauze into wound if necessary, and ensure gauze does not touch skin around the wound. | Apply skin preparation as per agency protocol, if required. | ||
18. Cleanse around drain (if present). | Drain is cleansed using circular strokes starting near the drain and moving outward and away from the insertion site. | ||
19. Apply dry layer of sterile gauze over moist gauze using sterile technique. | This covers moist gauze and preserves moistness. | ||
20. Apply drain sponges/cut gauze to drain site if present. | |||
21. Cover with ABD (abdominal) pad or gauze, and fasten with tape. | |||
22. Discard non-sterile gloves according to agency policy and perform hand hygiene. | Hand hygiene reduces the risk of infection. | ||
23. Next:
| These steps ensure the patient’s continued safety. | ||
24. Document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate health care 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. | ||
Data source: Perry et al., 2014; WHO, 2009 |
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).
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 health care professional and according to agency guidelines.
Contraindications to packing a wound include a fistula tract, a wound with an unknown endpoint to tunnelling, 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 types of 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 impregnated gauze, ribbon dressing, hydro-fiber dressing, alginate antimicrobial dressing, and a negative pressure foam or gauze dressing. 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 4.6.
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, healability 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 settings. | ||
Type of solution for irrigation | The most common solution used is normal saline at room temperature, unless otherwise ordered. Check physician orders. | ||
Wound irrigation | The wound is irrigated each time the dressing is changed. | ||
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 is sufficient 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. | ||
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 tunnelling 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. | ||
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 1cm (>1cm), 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 health care facility. | ||
Use of sterile gloves for packing | Sterile gloves may be used if packing a large or complex wound. | ||
Data source: British Columbia Provincial Nursing Skin and Wound Committee, 2014; Saskatoon Health Region, 2013 |
The health care professional chooses the method of cleansing (a squeezable sterile normal saline container or a 30 to 35 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, but sterile normal saline and sterile water are the solutions of choice for cleansing wounds and should be warmed to support wound healing.
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 or physician or NP.
Checklist 38 outlines the steps for irrigating and packing a wound.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Review order for wound irrigation and packing. | Confirm that physician’s orders are appropriate to wound assessment. | ||
2. Perform hand hygiene. | Hand hygiene reduces the risk of infection. | ||
3. Gather necessary equipment and supplies:
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. | ||
4. Position patient to allow solution to flow off patient. Position patient so wound is vertical to the collection basin. | |||
5. Place waterproof pad under patient. Apply clean gloves. Set up sterile field and supplies. | Protect patient’s clothing and bedding from irrigation fluid. | ||
6. 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. All packing must be removed with each dressing change. | ||
7. 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 agency policy. | The use of personal protective equipment (PPE) reduces the risk of contamination. | ||
9. Fill 35 to 60 ml syringe with sterile water/irrigating solution and attach a needleless cannula to end of syringe. | |||
10. Hold syringe about 1 inch above 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 a small needleless catheter to prefilled irrigation syringe and insert about 1/2 inch. Use slow continuous pressure to flush wound. Repeat flushing procedure until returns run clear into the basin. | 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. Dry wound edges with sterile gauze using sterile forceps. | This step prevents maceration of surrounding tissue from excess moisture. | ||
12. Remove goggles or face shield. | PPE is no longer required after irrigating a wound. | ||
13. Perform hand hygiene and apply sterile gloves (if not using sterile forceps) or non-sterile gloves. | Hand hygiene reduces the risk of infection. | ||
14. Apply a skin barrier / protectant on the peri-wound skin as needed. | Saturated packing materials and/or wound exudate may macerate or irritate unprotected peri-wound skin. | ||
15. For normal saline gauze packing:
| The wound must be moist, not wet, for optimal healing. Gauze packing that is too wet can cause tissue maceration and reduces the absorbency of the gauze. Normal saline gauze packing needs to be changed at least once daily. 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. Ensure the wound is not over-packed or under-packed as this may diminish the healing process. This prepares the wound bed for optimal healing with a moist to dry dressing. | ||
16. Open gauze and gently pack it into wound using either forceps or the tip of a cotton swab stick. | Continue until all wound surfaces are in contact with gauze. Do not pack too tightly. Do not overlap wound edges with wet packing. | ||
17. 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. | 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. | ||
18. Apply an appropriate outer dry dressing, depending on the frequency of the dressing changes and the amount of exudate from the wound. | The dressing on the wound must remain dry on the outside until the next dressing change to avoid cross-contamination of the wound. | ||
19. Discard supplies and perform hand hygiene. | This prevents the transfer of microorganisms. | ||
20. Help patient back into a comfortable position, and lower the bed. | This step optimizes patient safety. | ||
21. Document wound assessment, irrigation solution, and patient response to the irrigation and dressing change. Documentation should include date and time of procedure. Report any unusual findings or concerns to the appropriate health care professional. | This allows for effective communication between health care providers. Notify required health care providers if wound appears infected or is not healing as expected. | ||
Data source: BCIT, 2010b; Perry et al., 2014 |
The following links provide additional information about wound packing and wound measuring.
Critical Thinking Exercises
Drains 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 an organ, duct, or a cavity such as a hematoma. The number of drains depends on the extent and type of surgery. A closed system uses a vacuum system to withdraw fluids and collects the drainage into a reservoir. Closed systems must be emptied and measured at least once every shift and cleaned using sterile technique according to agency protocol.
Drainage tubes consist of silastic tubes with perforations to allow fluid to drain from the surgical wound site, or separate puncture holes close to the surgical area. The drainage is collected in a closed sterile collection system/reservoir (Hemovac or Jackson-Pratt) or an open system that deposits the drainage on a sterile dressing. Drainage may vary depending on location and type of surgery. A Hemovac drain (see Figure 4.3) can hold up to 500 ml of drainage. A Jackson-Pratt (JP) drain (see Figure 4.4) is usually used for smaller amounts of drainage (25 to 50 ml). Drains are usually sutured to the skin to prevent accidental removal. The drainage site is covered with a sterile dressing and should be checked periodically to ensure the drain is functioning effectively and that no leaking is occurring.
Checklist 39 outlines the steps to take when emptying a closed wound drainage system.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Perform hand hygiene. | Hand hygiene reduces the risk of infection. | ||
2. Collect the necessary supplies. | For example: drainage measurement container, non-sterile gloves, waterproof pad, and alcohol swab | ||
3. Apply non-sterile gloves and goggles or face shield according to agency protocols. | Personal protective equipment reduces the transmission of microorganisms and protects against an accidental body fluid exposure. | ||
4. Maintaining sterile technique, remove plug from pouring spout as indicated on drain. | Open plug pointing away from your face to avoid an accidental splash of contaminated fluid. Maintain the plug’s sterility. The vacuum will be broken and the reservoir (drainage collection system) will expand. | ||
5. Gently tilt the opening of the reservoir toward the measuring container and pour out the drainage. | Pour away from yourself to prevent exposure to body fluids. | ||
6. Place drainage container on bed or hard surface, tilt away from your face, and compress the drain to flatten it with one hand. With the other hand, swab the surface of the port, then insert the plug to close the drainage system. | Gently squeezing the drain to flatten and remove all the air prior to closing the spout will establish the vacuum system. | ||
7. Place the plug back into the pour spout of the drainage system, maintaining sterility. | This establishes vacuum suction for drainage system. | ||
8. Secure device onto patient’s gown using a safety pin; check patency and placement of tube. Ensure that enough slack is present in tubing, and that reservoir hangs lower than the wound. | Proper placement of the reservoir allows gravity to facilitate wound drainage. Providing enough slack to accommodate patient movement prevents tension of the drainage system and pulling on the tubing and insertion site. | ||
9. Note character of drainage: colour, consistency, odour, amount. Discard drainage according to agency policy. | Drainage counts as patient fluid output and must be documented on 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. | ||
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. | ||
11. Document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate health care professional. | This allows for an accurate recording of drainage. Record the number the drains if there is more than one, and record each one separately. If the amount of drainage increases or changes, notify the appropriate health care provider according to agency policy. If amount of drainage significantly decreases, the drain may be ready to be assessed and removed. | ||
Data source: BCIT, 2010b; Perry et al., 2014 |
Removal of a drain must be ordered by the physician or NP. A drain is usually in place for 24 to 48 hours, and removal depends on the amount of drainage over the last 24 hours.
Checklist 40 outlines the steps for removing a wound drainage system.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Confirm that the physician order correlates with amount of drainage in the past 24 hours. | Physicians should specify an amount for acceptable drainage for the drain to be removed. | ||
2. Explain procedure to patient; offer analgesia and bathroom as required. | Taking this step decrease the patient’s anxiety about the procedure. Explain to the patient that a pulling 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 a sterile blade, cleansing solution, extra gauze, tape, garbage bag. | Organizing supplies helps the procedure occur as efficiently as possible for the patient. | ||
4. Apply a waterproof drape/pad for depositing the drain once it has been removed. | This provides a place to put the drain once it is removed. | ||
5. Perform hand hygiene. | Hand hygiene reduces the risk of infection. | ||
6. Apply non-sterile gloves and face shield according to agency policy. | Personal protective equipment reduces the potential for accidental exposure to blood or body fluids. | ||
7. Release suction on reservoir and empty; measure and record drainage if >10 ml. | Releasing suction reduces potential for tissue damage as drain is removed. | ||
8. Remove tape and dressing from drain insertion site. | Remove tape to allow for ease of drain removal. | ||
9. Cleanse site according to simple dressing change procedure. | This step prevents infection of the site and allows the suture to be easily seen for removal. | ||
10. Carefully cut and remove suture anchoring drain with sterile suture scissors or a sterile blade. | Snip beneath the suture knot to ensure contaminated suture is not brought into the tissue. Pull suture out. Snip or cut knot away from yourself. | ||
11. Stabilize skin with non-dominant hand. | Applying counterpressure to skin near the drain decreases discomfort to patient. | ||
12. Ask patient to take a deep breath and exhale slowly; remove the drain as the patient exhales. | This step helps the patient prepare for removal of the drain. | ||
13. Firmly grasp drainage tube close to skin with dominant hand, and with a swift and steady motion withdraw the drain and place it on the waterproof drape/pad (other hand should stabilize skin with 4 x 4 sterile gauze around drain site). | Slight resistance may be felt. If there is strong resistance, stop, cover site, and call physician. Ensure the drainage tip is intact. The end of the drainage tip should be smooth. Some agencies require that the tip be sent for lab analysis for microorganisms. When pulling out drain, gather up the drain tubing in your hand as it’s being removed. | ||
14. Place drain and tube on waterproof pad or in garbage bag to be disposed of after procedure is complete. | This step prevents the drain and tube from contaminating bed or floor. | ||
15. Remove gloves and apply new non-sterile gloves. | This prevents contamination of the drain site. | ||
16. Cleanse old drain site using aseptic technique according to simple dressing change procedure. | This step prevents contamination of the drain site. | ||
17. Cover drain site with sterile dressing. | |||
18 Assist patient back to comfortable position and lower bed. | This ensures patient safety and comfort after the procedure. | ||
19. Discard drain in biohazard waste as per hospital policy. | This prevents the spread of microorganisms. | ||
20. Perform hand hygiene. | Hand hygiene prevents the spread of infection. | ||
21. Document output and drain removal. | Record drainage according to agency policy. | ||
22. Assess dressing 30 minutes after drain removal. | Monitor for excessive drainage from the drainage site. | ||
23. Document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate health care professional. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: BCIT, 2010b; Perry et al., 2014; Saskatoon Health Region, 2012 |
Critical Thinking Exercises
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
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). Guidelines: Assessment and treatment of surgical wounds healing by primary and secondary intention in adults and children. Retrieved on April 25, 2015, from https://www.clwk.ca/buddydrive/file/guideline-surgical-wounds-primary-secondary-intention/?download=102%25253Aguideline-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 on April 25, 2015, from https://www.clwk.ca/buddydrive/file/guideline-braden-risk-assessment/
Gallagher-Camden, S. (2012). Skin care needs of the obese patient. In Bryant, R. A., & Nix, D. P. (Eds.). Acute and chronic wounds: Current management concepts (4th ed.). St Louis, MO: Mosby.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.
Saskatoon Health Region. (2013). Drains: Emptying, shortening and removal. Policies and procedures. Retrieved on May, 2012, from https://www.saskatoonhealthregion.ca/about/NursingManual/1100.pdf
Spiliotis, J., Tsiveriotis, K., Datsis, A. D., Vaxevanidou, A., Zacharis, G., Giafis, K., Kekelos, S., & Rogdakis, A. (2009). Wound dehiscence: Is still a problem in the 21st century: A retrospective study. Retrieved on June 23, 2015, from http://www.wjes.org/content/4/1/12
Stotts, N. A. (2012). Nutritional assessment and support. In Bryant, R. A., & Nix, D.P. (Eds.). Acute and chronic wounds: Current management concepts (4th ed.). St Louis, MO: Mosby
World Health Organization. (2009). Glove use information leaflet. Retrieved from WHO: Patient Safety. Retrieved on June 23, 2015, from http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf
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, 2014).
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 Objectives
The air we breathe is made up of various gases, 21% of which is oxygen. 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.
Hemoglobin (Hgb) 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.
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 (Simpson, 2004). For patients with COPD, the target SaO2 range is 88% to 92% (Alberta Health Services, 2015; British Thoracic Society, 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.
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 (Metrovic, 2014), but by pulse oximetry and SpO2 (British Thoracic Society, 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.
The Vancouver Coastal Health Authority (2015) lists three causes of hypoxemia: deadspace and shunts, low inspired oxygen tension, and alveolar hypoventilation.
Ventilation and perfusion are not always equal between the alveoli and pulmonary capillaries. There is sometimes too much perfusion and not enough ventilation in some areas of the lungs, causing a shunt where the blood is unable to pick up oxygen and unload carbon dioxide. In other areas of the lungs, there may be too much ventilation and not enough perfusion, causing deadspace where oxygen is unable to diffuse into the blood.
Hypoxemia can be caused by breathing air at pressures less than atmospheric pressure, such as at high altitudes or in an enclosed space with inadequate ventilation. The enclosed space may be especially hazardous if there is a low concentration of oxygen or if it contains toxic gases.
If a patient hypoventilates, the level of oxygen in the alveoli will fall, and the level of carbon dioxide will increase. Hypoxemia occurs because less oxygen is moved into the pulmonary blood flow.
Examples of medical conditions that 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 (British Thoracic Society, 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.
Hypoxia is a medical emergency (Alberta Health Services, 2015). Oxygen therapy will:
Critical Thinking Exercises
Oxygen saturation, sometimes referred to as ‘‘the fifth vital sign,” should be checked by pulse oximetry in all breathless and acutely ill patients (British Thoracic Society, 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 (see Figure 5.1) is indicated in patients who have, or are at risk for, impaired gaseous exchange or an unstable oxygen status.
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.
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.
Another common cause of inaccuracy is poor peripheral perfusion. Poor peripheral perfusion can be caused by conditions such as hypothermia, peripheral vascular disease, vasoconstriction, hypotension, or peripheral edema (Perry, Potter, & Ostendorf, 2014). 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).
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.
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).
Critical Thinking Exercises
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 5.1, 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).
Safety considerations:
| |||
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: British Thoracic Society, 2008; Perry et al., 2014 |
Critical Thinking Exercises
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 (British Thoracic Society, 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 (SaO2) for a normal adult is 92% to 98%. For patients with COPD, the target SaO2 range is 88% to 92% (Alberta Health Services, 2015; British Thoracic Society, 2008; Kane, et al., 2013).
Although all medications given in the hospital require a prescription, oxygen therapy may be initiated without a physician order in emergency situations. 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, pneumonthorax, 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).
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 (British Thoracic Society, 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 (British Thoracic Society, 2008). Table 5.2 lists the 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. | ||||||
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. | ||||||
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. 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. | ||||||
Partial re-breather mask (high-flow system) | The bag should always remain partially inflated. The flow rate should be high enough to keep the bag partially inflated. Advantages: Can deliver 10 to 12 L/min for an O2 concentration of 80% to 90%. Used short term for patients who require high levels of oxygen. Disadvantages: The partial re-breather bag has no one-way valves, so the expired air mixes with the inhaled air. The mask may be hot and confining for the patient and will interfere with eating and talking. | ||||||
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. | ||||||
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 membranes. Disadvantages: The mask may be hot and confining for some patients, and it interferes with talking and eating. Need a properly fitting mask. Nurses may be asked to set up a high-flow system. In other instances, respiratory therapists may be responsible for regulating and monitoring the high-flow systems. | ||||||
Data source: Perry et al., 2014; Vancouver Coastal Health Authority, 2015 |
The use of oxygen delivery systems is only one component to increasing oxygen to the alveolar capillary bed to allow for optimal oxygenation to the tissues. Additional methods to increase oxygen saturation levels in the body include (Perry et al., 2014):
Critical Thinking Exercises
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 rate, and to monitor the saturation rate to keep it within target range. The target range (SaO2) for a normal adult is 92 – 98%. For patients with COPD, the target SaO2 range is 88 – 92% (Alberta Health Services, 2015; Kane, et al., 2013; Perry et al., 2014).
Although all medications require a prescription, oxygen therapy may be initiated without a physician’s order in emergency situations. Hypoxia is considered an emergency situation. Most hospitals have a protocol in place allowing 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, pneumonthorax, and abnormalities in the quality and quantity of hemoglobin. There are no contradictions to oxygen therapy if indications for therapy are present (Kane et al., 2013).
Hypoxic patients must be assessed for the causes and underlying reasons for their hypoxia. Hypoxia must be managed not only with supplemental oxygen but in conjunction with the interventions outlined in Table 5.3.
Interventions | Additional Information | ||
Raise the head of the bed | Raising the head of the bed promotes effective breathing and diaphragmatic descent, maximizes inhalation, and decreases the work of breathing. Positioning enhances airway patency in all patients. A Fowler’s or semi-Fowler’s position promotes a patient’s chest expansion with the least amount of effort. Patients with COPD who are short of breath may gain relief by sitting with their back against a chair and rolling their head and shoulders forward or leaning over a bedside table while in bed. | ||
Deep breathing and coughing techniques | Deep breathing and coughing techniques help patients effectively clear their airway while maintaining their oxygen levels. Teach patients “controlled coughing” by having them take a deep breath in and cough deeply with the mouth slightly open. If they have difficulty coughing, teach the huffing technique. This involves taking a medium breath and then making a sound like “ha” to push the air out fast with the mouth slightly open. This is done three or four times, and then they are instructed to cough. If secretions are thick and tenacious, the patient may be dehydrated and require additional fluids (if medical condition does not contraindicate additional fluids). | ||
Oxygen therapy and equipment | If patient is already on supplemental oxygen, ensure equipment is turned on and set at the required flow rate and is connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment. In hospitals where medical air and oxygen are used, ensure patient is connected to the oxygen flow port. | ||
Assess need for bronchodilators | Pharmacological management is essential for patients with respiratory disease. Medications such as bronchodilators effectively relax smooth muscles and open airways in certain disease processes such as COPD. Glucocorticoids relieve inflammation and also assist in opening air passages. Mucolytics and adequate hydration decrease the thickness of pulmonary secretions so that they can be expectorated more easily. | ||
Oral suctioning | Some patients may have a weakened cough that inhibits their ability to clear secretions from the mouth and throat. Patients with muscle disorders or who have experienced a cerebral vascular accident (CVA) are at risk for aspiration related to ineffective cough reflex, which could lead to hypoxia. Provide oral suction if patient is unable to clear secretions, foreign debris, or mucous from the mouth and pharynx. See Checklist 42 for further directions. | ||
Pain relief | Provide adequate pain relief. Pain is known to increase the metabolic demands on the body, which in turn increases the need for more oxygen supply. | ||
Devices to enhance secretion clearance | Many devices assist with secretion clearance, such as vests that inflate with large volumes of air and vibrate the chest wall, and handheld devices that help provide positive expiratory pressure to prevent airway collapse in exhalation. Usefulness of these therapies is decided based on the individual patient’s situation and the preference of both the patient and care provider. | ||
Frequent rests in between activities | Patients experiencing hypoxia often feel short of breath (SOB) and fatigue easily. Allow patient to rest frequently, and space out interventions to decrease oxygen demand in patients whose reserves are likely limited. Has the patient just returned from a walk down the hall or to the bathroom? Assess for underlying causes of the hypoxia. Is the potential problem respiratory or cardiovascular? What underlying respiratory or cardiovascular conditions exist? Complete respiratory and cardiovascular assessments may reveal potential abnormalities in these systems. | ||
Obstructive sleep apnea | Patients with obstructive sleep apnea (OSA) may be unable to maintain a patent airway. In OSA, nasopharyngeal abnormalities that cause narrowing of the upper airway produce repetitive airway obstruction during sleep, with the potential for periods of apnea and hypoxemia. Pressure can be delivered during the inspiratory and expiratory phases of the respiratory cycle by using a mask to maintain airway patency during sleep. The process requires consideration of each individual’s needs in order to to obtain compliance. | ||
Anxiety and depression | The most common co-morbidities of COPD are anxiety and depression. Anxiety is related to chronic shortness of breath and an inability to breathe effectively. Anxiety and depression are chronically undertreated and may be relieved with breathing retraining, counselling, relaxation techniques, or anti-anxiety medications if appropriate. | ||
Data source: Cigna & Turner-Cigna, 2005; Kane et al., 2013; Maurer et al., 2008; Perry et al., 2007; Perry et al., 2014; Shackell & Gillespie, 2009 |
When providing oxygen therapy, remember the following (Kane et al., 2013):
Oxygen is available in hospitals through bulk liquid oxygen systems that dispense oxygen as a gas through outlets in rooms. It can also be provided in cylinders (large or small) for easy transport for patient use while mobile or when moving around the hospital. An oxygen flow meter regulates the flow in litres per minute. Oxygen therapy may be short- or long-term depending on the SaO2 requirements of the patients and underlying diseases processes (Perry et al., 2014).
Checklist 41 reviews the steps for applying and titrating oxygen therapy (see Figure 5.2).
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Complete respiratory assessment for hypoxia. SaO2 should be greater than 92% unless otherwise stated by the physician. The goal is to use the least amount of oxygen to maintain levels between 92% and 98%. | Assess need for O2: check SaO2 level with a pulse oximetry device. Assess for underlying medical conditions or alternate causes of hypoxia (cardiovascular). | ||
2. If a patient requires oxygen therapy, choose an oxygen delivery system based on your patient’s requirements. | Oxygen is initially started at a low concentration (2 L/min) using nasal prongs. Then the flow is titrated up to maintain oxygen saturation of 92% or greater. Selection of delivery system is based on the level of oxygen support required (controlled or non-controlled), the severity of hypoxia, and the disease process. Other factors include age, presence of underlying disease (COPD), level of health, presence of an artificial airway, and environment (home or hospital). Significant decreases to O2 saturation levels or large increases to maintain O2 saturation should be reported promptly to responsible health care provider. | ||
3. Once oxygen is applied, reassess your patient in 5 minutes to determine the effects on the body. | Hypoxia should be reduced or prevented. O2 levels should be between 92% and 98%. Assess vital signs, respiratory and cardiovascular systems, and level of consciousness. Assess and implement additional treatments for hypoxia if appropriate. Reassess your patient if signs and symptoms of hypoxia return. | ||
4. If required, adjust O2 levels. | Changes in O2 percentages should be in 5% to 10% increments. Patients should be reassessed (respiratory assessment including O2 saturations) after 5 minutes following any changes to oxygenation levels. Changes in litre flow should be in 1 to 2 L increments. Consider changing O2 delivery device if O2 saturation levels are not maintained in target range. Slow, laboured breathing is a sign of respiratory failure. | ||
5. If hypoxia continues, contact respiratory therapist or physician for further orders according to agency protocol. | Patient may require further interventions from the respiratory therapist or most responsible health care provider. Signs and symptoms of respiratory deterioration include increased respiratory rate, increased requirement of supplemental oxygen, inability to maintain target saturation level, drowsiness, decrease in level of consciousness, headache, or tremors. | ||
Data source: British Thoracic Society, 2008; Perry et al., 2014 |
Critical Thinking Exercises
Oxygen therapy supports life and supports combustion. While there are many benefits to inhaled oxygen, there are also hazards and side effects. Anyone involved in the administration of oxygen should be aware of potential hazards and side effects of this medication. Oxygen should be administered cautiously and according to the safety guidelines listed in Table 5.4.
Guideline | Additional Information |
Oxygen is a medication. | Remind patient that oxygen is a medication and should not be adjusted without consultation with a physician or respiratory therapist. |
Storage of oxygen cylinders | When using oxygen cylinders, store them upright, chained, or in appropriate holders so that they will not fall over. |
No smoking | Oxygen supports combustion. No smoking is permitted around any oxygen delivery devices in the hospital or home environment. |
Keep oxygen cylinders away from heat sources. | Keep oxygen delivery systems at least 1.5 metres from any heat source. |
Check for electrical hazards in the home or hospital prior to use. | Determine that electrical equipment in the room or home is in safe working condition. A small electrical spark in the presence of oxygen will result in a serious fire. The use of a gas stove, kerosene space heater, or smoker is unsafe in the presence of oxygen. Avoid items that may create a spark (e.g., electrical razor, hair dryer, synthetic fabrics that cause static electricity, or mechanical toys) with nasal cannula in use. |
Check levels of oxygen in portable tanks. | Check oxygen levels of portable tanks before transporting a patient to ensure that there is enough oxygen in the tank. |
ABGs should be ordered for all critically ill patients on oxygen therapy. | High concentrations of oxygen therapy should be closely monitored with formal assessments (pulse oximetry and ABGs). |
Data source: British Thoracic Society, 2008; Perry et al., 2014 |
Oxygen is essential to life, but as a drug it has both a maximum positive benefit and an accompanying toxicity effect. The toxic effects from oxygen therapy can occur based on the condition of the patient and the duration and intensity of the oxygen therapy. For example, with normal lung function, a stimulation to take another breath occurs when a patient has a slight rise in PaCO2. The slight rise in PaCO2 stimulates the respiratory centre in the brain, creating the impulse to take another breath. In some patients with a chronically high level of PaCO2, such as those with chronic obstructive pulmonary disease (COPD), the stimulus and drive to breathe is caused by a decrease in PaO2. This is called a hypoxic drive. When administering oxygen to patients with known CO2 retention, watch for signs of hypoventilation, a decreased level of consciousness, and apnea.
Oxygen therapy can have harmful effects, which are dependent on the duration and intensity of the oxygen therapy. See Table 5.5 for precautions and complications of oxygen therapy.
Complications | Precautions |
Oxygen-induced hypoventilation/ hypoxic drive | If patients with a hypoxic drive are given a high concentration of oxygen, their primary urge to breathe is removed and hypoventilation or apnea may occur. It is important to note that not all COPD patients have chronic retention of CO2, and not all patients with CO2 retention have a hypoxic drive. It is not commonly seen in clinical practice. Never deprive any patient of oxygen if it is clinically indicated. It is usually acceptable to administer whatever concentration of oxygen is needed to maintain the SpO2 between 88% and 92% in patients with known chronic CO2 retention verified by an ABG. |
Absorption actelectasis | About 80% of the gas in the alveoli is nitrogen. If high concentrations of oxygen are provided, the nitrogen is displaced. When the oxygen diffuses across the alveolar-capillary membrane into the bloodstream, the nitrogen is no longer present to distend the alveoli (called a nitrogen washout). This reduction in alveolar volume results in a form of collapse called absorption atelectasis. This situation also causes an increase in the physiologic shunt and resulting hypoxemia. |
Oxygen toxicity | Oxygen toxicity, caused by excessive or inappropriate supplemental oxygen, can cause severe damage to the lungs and other organ systems. High concentrations of oxygen, over a long period of time, can increase free radical formation, leading to damaged membranes, proteins, and cell structures in the lungs. It can cause a spectrum of lung injuries ranging from mild tracheobronchitis to diffuse alveolar damage. For this reason, oxygen should be administered so that appropriate target saturation levels are maintained. Supplemental oxygen should be administered cautiously to patients with herbicide poisoning and to patients receiving bleomycin. These agents have the ability to increase the rate of development of oxygen toxicity. |
Data source: British Thoracic Society, 2008; Perry et al., 2014. |
Critical Thinking Exercises
The purpose of oral suctioning is to maintain a patent airway and improve oxygenation by removing mucous secretions and foreign material (vomit or gastric secretions) from the mouth and throat (oropharynx). Oral suction is the use of a rigid plastic suction catheter, known as a yankauer (see Figure 5.3), to remove pharyngeal secretions through the mouth (Perry et al., 2014). The suction catheter has a large hole for the thumb to cover to initiate suction, along with smaller holes along the end, which mucous enters when suction is applied. The oral suctioning catheter is not used for tracheotomies due to its large size. Oral suctioning is useful to clear secretions from the mouth in the event a patient is unable to remove secretions or foreign matter by effective coughing. Patients who benefit the most include those with CVAs, drooling, impaired cough reflex related to age or condition, or impaired swallowing (Perry et al., 2014). The procedure for oral suctioning can be found in Checklist 42.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Assess patient need for suctioning (respiratory assessment for signs of hypoxia), risk for aspiration, and inability to protect own airway or clear secretions adequately, which may lead to upper airway obstruction. | Baseline respiratory assessment, including an O2 saturation level, can alert the health care provider to worsening condition. Signs and symptoms include obvious excessive secretions; weak, ineffective cough; drooling; gastric secretions or vomit in the mouth; or gurgling sounds with inspiration and expiration. Pooling of secretions may lead to obstruction of airway. Suctioning is required with alterations in oxygen levels and with increased secretions. | ||
2. Explain to patient how the procedure will help clear out secretions and will only last a few seconds. If appropriate, encourage patient to cough. | This allows patient time to ask questions and increase compliance with the procedure. Minimizes fear and anxiety. Encourage the patient to cough to bring secretions from the lower airways to the upper airways. | ||
3. Position patient in semi-Fowler’s position with head turned to the side. | This facilitates ease of suctioning. Unconscious patients should be in the lateral position. | ||
4. Perform hand hygiene, gather supplies, and apply non-sterile gloves. Apply mask if a body fluid splash is likely to occur. | This prevents the transmission of microorganisms. Supplies include a suction machine or suction connection, connection tubing, non-sterile gloves, yankauer, water and a sterile basin, mask, and clean towel. Suctioning may cause splashing of body fluids. | ||
5. Fill basin with water. | Water is used to clear connection tubing in between suctions. Fill basin with enough water to clear the connection tubing at least three times. | ||
6. Attach one end of connection tubing to the suction machine and the other end to the yankauer. | This prepares equipment to function effectively. | ||
7. Turn on suction to the required level. Test function by covering hole on the yankaeur with your thumb and suctioning up a small amount of water. | Suction levels for adults are 100-150 mmHg on wall suction and 10-15 mmHg on portable suction units. Always refer to hospital policy for suction levels. | ||
8. Remove patient’s oxygen mask if present. Nasal prongs may be left in place. Place towel on patient’s chest. | Always be prepared to replace the oxygen if patient becomes short of breath or has decreased O2 saturation levels. The towel prevents patient from coming in contact with secretions. | ||
9. Insert yankauer catheter and apply suction by covering the thumb hole. Run catheter along gum line to the pharynx in a circular motion, keeping yankauer moving. Encourage patient to cough. | Movement prevents the catheter from suctioning to the oral mucosa and causing trauma to the tissues. Coughing helps move secretions from the lower airways to the upper airways. Apply suction for a maximum of 10 to 15 seconds. Allow patient to rest in between suction for 30 seconds to 1 minute. | ||
10. If required, replace oxygen on patient and clear out suction catheter by placing yankauer in the basin of water. | Replace oxygen to prevent or minimize hypoxia. Clearing out the catheter prevents the connection tubing from plugging. | ||
11. Reassess and repeat oral suctioning if required. | Compare pre- and post-suction assessments to determine if intervention was effective. | ||
12. Reassess respiratory status and O2 saturation for improvements. Call for help if any abnormal signs and symptoms appear. | This identifies positive response to suctioning procedure and provides objective measure of effectiveness. | ||
13. Ensure patient is in a comfortable position and call bell is within reach. Provide oral hygiene if required. | This promotes patient comfort. | ||
14. Clean up supplies, remove gloves, and wash hands. Document procedure according to hospital policy. | Cleanup prevents the transmission of microorganisms. Documentation provides accurate details of response to suctioning and clear communication among the health care team. | ||
Data source: Perry et al., 2014; Potter et al., 2010 |
Critical Thinking Exercises
Oxygen is essential to life. The main goal of oxygen therapy is to prevent hypoxemia, thereby preventing hypoxia that could result in tissue damage and cell death. Hypoxia, if caused by certain medical conditions, can be managed and prevented by oxygen therapy. In other instances, such as with anemia and decreased cardiac output, the effects of oxygen therapy will be limited.
Always follow the guiding principles of the oxygen therapy protocols of your local health authority to administer oxygen safely to manage hypoxia and prevent the side effects and hazards of oxygen therapy.
Key Takeaways
Alberta Health Services. (2015). Oxygen therapy for acute adult inpatients. Learning module for allied health staff (level 1 and 2). Retrieved on May 1, 2015, from http://www.albertahealthservices.ca/assets/info/hp/edu/if-hp-edu-ahc-oxygen-therapy-learning-module-cat-1and2.pdf
British Thoracic Society. (2008). Guideline for emergency oxygen use in adult patients. Thorax, 63(suppl.VI). Retreived on May 1, 2015, from https://www.brit-thoracic.org.uk/document-library/clinical-information/oxygen/emergency-oxygen-use-in-adult-patients-guideline/emergency-oxygen-use-in-adult-patients-guideline/
Cigna, J. A., & Turner-Cigna, L. M. (2005). Rehabilitation for the home care patient with COPD. Home Healthcare Nurse 23(9), 578-584.
Howell, M. (2002, March). The correct use of pulse oximetry in measuring oxygen status. Retrieved on November 12, 2015, from http://www.nursingtimes.net/the-correct-use-of-pulse-oximetry-in-measuring-oxygen-status/199984.article
Jardins, T., & Burton, G. G. (2011). Clinical manifestations and assessment of respiratory diseases (6th ed.). St Louis; MO: Elsevier-Mosby.
Kane, B., Decalmer, S., & O’Driscoll, B. R. (2013). Emergency oxygen therapy: From guideline to implementation. Breathe, 9(4) 246-253. doi: 10.1183/20734735.025212l
Maurer, J., Rebbapragada, V., Borson, S., Goldstein, R., Kunik, M., Yohannes, A., & Hanania, N. (2008). Understanding depression and COPD. Current understanding, unanswered questions and research needs. Chest, 134(4), 43s-56s. doi: 10.1378/chest.08-0342
Metrovic, T. (2014). What is Hypoxemia? Retrieved on May 3, 2015, from http://www.news-medical.net/health/What-is-Hypoxemia.aspx
Perry, A. G., Potter, P. A., & Elkin, M. K. (2007). Nursing interventions and clinical skills (5th ed.). St Louis, MO: Elsevier-Mosby.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques. (8th ed.). St Louis, MO: Elsevier-Mosby.
Potter, P. A., Perry, A. G., Ross-Kerr, J. C., & Wood, M. J. (Eds.). (2010). Canadian fundamentals of nursing (4th ed.). Toronto: Elsevier Canada.
Providence Health Care. (2008). Nursing care standards: Oxygen therapy protocol. Vancouver, BC: Providence Health Care.
Shackell, E., & Gillespie, M. (2009). The oxygen supply and demand framework: A tool to support integrative learning. Canadian association of critical care nurses, 20(4), 15-19. Retrieved on April 1, 2015, from http://www.bcit.ca/files/health/bsnpreceptors/oxygen_supply_and_demand_framework_tool_support_integrative_learning.pdf
Simpson, H. (2004). Interpretation of arterial blood gases: A clinical guide for nurses. British journal of nursing, 13(9), 522-528.
The nurse is the health care professional who will administer medication. This chapter describes responsibilities related to nurses in the administration of all medications except parenteral (see Chapter 7). Medications can be administered by a variety of routes or methods, each determined by the different preparations of drugs that influence the absorption, distribution, metabolism, and excretion (pharmacokinetics) in the body. It is imperative that the appropriate form of a drug be administered.
Every medication has the potential to harm a patient. Nurses must be aware that:
The nurse administering medication is responsible for ensuring full understanding of medication administration and its implications for patient safety.
Learning Objectives
In the Institute of Medicine’s often-cited book To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000), it is estimated that approximately 1.5-million preventable adverse drug events (ADEs) occur annually. The Joint Commission (TJC) defines medication errors as any preventable event that may cause inappropriate medication use or jeopardize patient safety (TJC, 2012).
Medication errors are the number-one error in health care (Centers for Disease Control [CDC], 2013). Safe and accurate medication administration is an important and potentially challenging nursing responsibility. Medication administration requires good decision-making skills and clinical judgment, and the nurse is responsible for ensuring full understanding of medication administration and its implications for patient safety.
Medication errors have a substantial impact on health care in Canada (Butt, 2010). When preparing and administering medication, and assessing patients after receiving medication, always follow agency policy to ensure safe practice. Review Table 6.1 for guidelines for safe medication administration.
Safety Considerations:
| |||
Principle | Additional Information | ||
Be vigilant when preparing medications. | Avoid distractions. Some agencies have a no-interruption zone (NIZ), where health care providers can prepare medications without interruptions. | ||
Check for allergies. | Always ask patient about allergies, types of reactions, and severity of reactions. | ||
Use two patient identifiers at all times. Always follow agency policy for patient identification. | Use at least two patient identifiers before administration and compare against the MAR. | ||
Assessment comes before medication administration. | All medications require an assessment (review of lab values, pain, respiratory assessment, cardiac assessment, etc.) prior to medication administration to ensure the patient is receiving the correct medication for the correct reason. | ||
Be diligent in all medication calculations. | Errors in medication calculations have contributed to dosage errors, especially when adjusting or titrating dosages. | ||
Avoid reliance on memory; use checklists and memory aids. | Slips in memory are caused by lack of attention, fatigue, distractions. Mistakes are often referred to as attentional behaviours where lack of training or knowledge is the cause of the error. Slips account for most errors in heath care. If possible, follow a standard list of steps for every patient. | ||
Communicate with your patient before and after administration. | Provide information to patient about the medication before administering it. Answer questions regarding usage, dose, and special considerations. Give the patient an opportunity to ask questions. Include family members if appropriate. | ||
Avoid workarounds. | A workaround is a process that bypasses a procedure, policy, or problem in a system. For example, a nurse may “borrow” a medication from another patient while waiting for an order to be filled by the pharmacy. These workarounds fail to follow agency policy to ensure safe medication practices. | ||
Ensure medication has not expired. | Medication may be inactive if expired. | ||
Always clarify an order or procedure that is unclear. | Always ask for help whenever you are uncertain or unclear about an order. Consult with the pharmacist, charge nurse, or other health care providers and be sure to resolve all questions before proceeding with medication administration. | ||
Use available technology to administer medications. | Bar-code scanning (eMAR) has decreased errors in administration by 51%, and computerized physician orders have decreased errors by 81%. Technology has the potential to help decrease errors. Use technology when administering medications but be aware of technology-induced errors. | ||
Report all near misses, errors, and adverse reactions. | Reporting allows for analysis and identification of potential errors, which can lead to improvements and sharing of information for safer patient care. | ||
Be alert to error-prone situations and high-alert medications. | High-alert medications are those that are most likely to cause significant harm, even when used as intended. The most common high-alert medications are anticoagulants, narcotics and opiates, insulins, and sedatives. The types of harm most commonly associated with these medications include hypotension, delirium, bleeding, hypoglycemia, bradycardia, and lethargy. | ||
If a patient questions or expresses concern about a medication, stop and do not administer it. | If a patient questions a medication, stop and explore the patient’s concerns, review the physician’s order, and, if necessary, notify the practitioner in charge of the patient. | ||
Data source: Agency for Healthcare Research and Quality, 2014; Canadian Patient Safety Institute, 2012; Debono et al., 2013; Institute for Healthcare Improvement, 2015; National Patient Safety Agency, 2009; National Priority Partnership, 2010; Prakash et al., 2014 |
Computerized physician order entry (CPOE) is a system that allows prescribers to electronically enter orders for medications, thus eliminating the need for written orders. CPOE increases the accuracy and legibility of medication orders; the potential for the integration of clinical decision support; and the optimization of prescriber, nurse, and pharmacist time (Agrawal, 2009). Decision support software integrated into a CPOE system can allow for the automatic checking of drug allergies, dosage indications, baseline laboratory results, and potential drug interactions. When a prescriber enters an order through CPOE, the information about the order will then transmit to the pharmacy and ultimately to the MAR.
The use of electronic bar codes on medication labels and packaging has the potential to improve patient safety in a number of ways. A patient’s MAR is entered into the hospital’s information system and encoded into the patient’s wristband, which is accessible to the nurse through a handheld device. When administering a medication, the nurse scans the patient’s medical record number on the wristband, and the bar code on the drug. The computer processes the scanned information, charts it, and updates the patient’s MAR record appropriately (Poon et al., 2010).
Automated medication dispensing systems (AMDS) provide electronic automated control of all medications, including narcotics. Each nurse accessing the system has a unique access code. The nurse will enter the patient’s name, the medication, the dosage, and the route of administration. The system will then open either the patient’s individual drawer or the narcotic drawer to dispense the specific medication. If the patient’s electronic health record is linked to the AMDS, the medication and the nurse who accessed the system will be linked to the patient’s electronic record.
Checklist 43 outlines the steps for safe medication administration.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Compare MAR with patient wristband. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (this must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking the drug to the bedside (e.g., eye drops), do a third check at the bedside. | ||
4. Circle medication when poured. | Pour medication. Circle MAR to show that medication has been poured. | ||
5. Positioning:
| This ensures patient safety and comfort. | ||
6. Post-medication safety check:
| This ensures patient safety. This step prevents the transfer of microorganisms. | ||
Data source: Lilley, Harrington, Snyder, & Swart, 2011; Lynn, 2011; Perry et al., 2014 |
Critical Thinking Exercises
Medication is usually given orally, which is generally the most comfortable and convenient route for the patient. Medication given orally has a slower onset and a more prolonged, but less potent, effect than medication administered by other routes (Lynn, 2011).
Prior to oral administration of medications, ensure that the patient has no contraindications to receiving oral medication, is able to swallow, and is not on gastric suction. If the patient is having difficulty swallowing (dysphagia), some tablets may be crushed using a clean mortar and pestle for easier administration. Verify that a tablet may be crushed by consulting a drug reference or a pharmacist. Medications such as enteric-coated tablets, capsules, and sustained-release or long-acting drugs should never be crushed because doing so will affect the intended action of the medication. Tablets should be crushed one at a time and not mixed, so that it is possible to tell drugs apart if there is a spill. You may mix the medication in a small amount of soft food, such as applesauce or pudding.
Position the patient in a side-lying or upright position to decrease the risk of aspiration. Offer a glass of water or other oral fluid (that is not contraindicated with the medication) to ease swallowing and improve absorption and dissolution of the medication, taking any fluid restrictions into account.
Remain with the patient until all medication has been swallowed before signing that you administered the medication.
Checklist 44 outlines the steps for administering medication by mouth.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Place all medications that patient will receive in one cup, except medications that require pre-assessment (e.g., blood pressure or pulse rate). Place these in a separate cup and keep wrapper intact. | Keeping medications that require pre-assessment separately acts as a reminder and makes it easier to withhold medications if necessary. | ||
5. Do not touch medication with ungloved hands. Use clean gloved hands if it is necessary to touch the medication. | Using gloves reduces contamination of the medication. | ||
6. Circle medication when poured. | Pour medication. Circle MAR to show that medication has been poured. | ||
7. Patient education
| The patient has the right to be informed and provided with reasons for medication, action, and potential adverse effects. Giving this information will likely improve adherence to medication therapy and patient reporting of adverse effects. Confirms patient’s allergy history. | ||
IMPORTANT: If patient expresses concerns over medications, do not give medication. Verify doctor’s order and explore patient concerns before administering medication. | |||
8. Positioning
| Correct positioning reduces risk of aspiration during swallowing. Water or other oral fluids will help with swallowing of medication. Proper body mechanics reduces risk of injury to health care provider. | ||
9. Administer medication orally as prescribed.
| Follow any specific descriptions for administration of the medication. Wear gloves if placing the medication inside the patient’s mouth.
| ||
10. Post-medication safety check
| Do not sign for any medications if you are not sure the patient has taken them. Post assessments determine effects and potential adverse effects of medications. | ||
11. Return within appropriate time to evaluate patient’s response to the medications and to check for possible adverse effects. If patient presents with any adverse effects:
| Most sublingual medications act in 15 minutes, and most oral medications act in 30 minutes.
| ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Patients with a gastric tube (nasogastric, nasointestinal, percutaneous endoscopic gastrostomy [PEG], or jejenostomy [J] tube) will often receive medication through this tube (Lynn, 2011). Liquid medications should always be used when possible because absorption is better and less likely to cause blockage of the tube. Certain solid forms of medication can be crushed and mixed with water prior to administration.
Checklist 45 outlines the steps for administering medication via a gastric tube.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Place all medications that patient will receive in one cup, except medications that require pre-assessment (e.g., blood pressure or pulse rate). Place these in a separate cup and keep wrapper intact. | Keeping medications that require pre-assessment separately acts as a reminder and makes it easier to withhold medications if necessary. | ||
5. Do not touch medication with ungloved hands. Use clean gloved hands if it is necessary to touch the medication. | Use gloves to reduce contamination of medication. | ||
6. Circle medication when poured. | Pour medication. Circle MAR to show that medication has been poured. | ||
7. Patient education:
| The patient has the right to be informed, and providing reasons for medication, actions, and potential adverse effects will likely improve adherence to medication therapy and patient reporting of adverse effects. Confirm patient’s allergy history. | ||
IMPORTANT: If patient expresses concern about medications, do not give medication. Verify doctor’s order and explore patient concerns before administering medication. | |||
8. Help patient to a high sitting position unless contraindicated. | This position reduces risk of aspiration during swallowing. | ||
9. Determine if medication should be given with or without food. If the medication is to be given on an empty stomach, the enteral feeding may need to be stopped from 30 minutes before until 30 minutes after the medication is given. | Follow specific medication guidelines to ensure adequate absorption and distribution of the medication. | ||
10. Apply clean non-sterile gloves. | Using gloves prevents spread of microorganisms. | ||
11. Check gastric tube for correct placement as described in Chapter 10. | Ensure that tube is properly placed prior to administering medication to prevent aspiration. | ||
12. Dilute medication in 15 to 30 ml of water. | Dilution keeps the tube from blocking. | ||
13. Remove plunger from a 60 ml gastric tube syringe and attach syringe to the end of the gastric tube while pinching the gastric tube. | Make sure the tip of the syringe fits the end of the gastric tube. | ||
14. Pour medication and water solution into the 60 ml syringe, release pinch, and allow fluid to drain slowly by gravity into the gastric tube. | If fluid does not drain by gravity, gentle pressure may be applied using the plunger of the syringe, but do not force the medication through the tube. | ||
15. Flush 10 ml of water between medications. | This step prevents interactions between medications. | ||
16. After the last medication has been given, flush the tube with 30 ml of water. | Flushing prevents blocking of the tube. | ||
17. Keep the patient in a high sitting position to prevent aspiration. | This position prevents aspiration and encourages absorption of medication. | ||
18. Post-medication safety check:
| Post assessments determine effects and potential adverse effects of medications. | ||
19. Return within appropriate time frame to evaluate patient’s response to the medications and to check for possible adverse effects. If patient presents with any adverse effects:
| Evaluate patient for intended and adverse effects. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Critical Thinking Exercises
Drugs administered PR have a faster action than via the oral route and a higher bio-availability – that is, the amount of effective drug that is available is greater as it has not been influenced by upper gastrointestinal tract digestive processes. Rectal absorption results in more of the drug reaching the systemic circulation with less alteration on route. As well as being a more effective route for delivering medication, rectal administration also reduces side-effects of some drugs, such as gastric irritation, nausea and vomiting (Lowry, 2016, para 2). Rectal medications are given for their local effects in the gastrointestinal system (e.g., laxatives) or their systemic effects (e.g., analgesics when oral route is contraindicated). Rectal medications are contraindicated after rectal or bowel surgery, with rectal bleeding or prolapse, and with low platelet counts. Checklist 46 outlines the procedure for administering rectal suppositories or enemas.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. If possible, have patient defecate prior to rectal medication administration. | Medication should not be inserted into feces. | ||
5. Ensure that you have water-soluble lubricant available for medication administration. | Lubricant reduces friction as suppository enters rectal canal. | ||
6. Explain the procedure to the patient. If patient prefers to self-administer the suppository/enema, give specific instructions to patient on correct procedure. | Patient may feel more comfortable self-administering suppository. | ||
NOTE: Unintended vagal stimulation may occur, resulting in bradycardia in some patients. Be aware that the rectal route may not be suitable for certain cardiac conditions. Notify physician. | |||
7. Raise bed to working height.
| Positioning helps prevent injury to nurse administering medication. This protects patient’s privacy and facilitates relaxation. Drape protects linens from potential fecal drainage. | ||
8. Apply clean non-sterile gloves. | Gloves protect the nurse from contact with mucous membranes and body fluids. | ||
9. Assess patient for diarrhea or active rectal bleeding. | Rectal medications are contraindicated in these situations. | ||
10. Apply clean non-sterile gloves if previous gloves were soiled. | Gloves protect the nurse from contact with mucous membranes and body fluids. | ||
11. Remove wrapper from suppository/tip of enema and lubricate rounded tip of suppository and index finger of dominant hand with lubricant. If enema, lubricate only tip of enema. | Lubricant reduces friction as suppository/enema enters rectal canal. | ||
12. Separate buttocks with non-dominant hand and, using gloved index finger of dominant hand, insert suppository (rounded tip toward patient) into rectum toward umbilicus while having patient take a deep breath, exhale through the mouth, and relax anal sphincter. If enema: Expel air from enema and then insert tip of enema into rectum toward umbilicus while having patient take a deep breath, exhale through the mouth, and relax anal sphincter. | You should feel the anal sphincter close around your finger after insertion. Forcing the suppository/enema through a clenched sphincter will cause pain and, potentially, rectal damage. | ||
13. With your gloved finger, insert suppository along wall of rectum about 5 cm beyond anal sphincter. Do not insert the suppository into feces. If enema: roll plastic bottle from bottom to tip until all solution has entered rectum and colon. | Suppository should be against rectal mucosa for absorption and therapeutic action. Inserting suppository into feces will decrease its effectiveness. | ||
14. Option: A suppository may be given through a colostomy (not ileostomy) if prescribed. | The patient should lie supine and a small amount of lubricant should be used. | ||
15. Remove finger and wipe patient’s anal area. | Wiping removes excess lubricant and provides comfort to the patient. | ||
16. Ask patient to remain on side for 5 to 10 minutes. | This position helps prevent the expulsion of suppository. | ||
17. Discard gloves by turning them inside out and disposing of them and any used supplies as per agency policy. Perform hand hygiene. | Using gloves reduces transfer of microorganisms. | ||
18. Ensure call bell is nearby and bedpan/commode is available and close by. | If suppository is a laxative or stool softener, patient will require a bedpan/commode or close proximity to toilet. | ||
19. Document procedure as per agency policy and include patient’s tolerance of administration. | Timely and accurate documentation promotes patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Female patients may require vaginal suppositories to treat vaginal infections. Vaginal suppositories are larger and more oval than rectal suppositories, and are inserted with an applicator (see Figure 6.2) or by hand (see Figure 6.3). Checklist 47 outlines the procedure for administering vaginal suppositories or medications.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | ||||
Safety considerations:
| ||||
Steps | Additional Information | |||
1. Check MAR against doctor’s orders. | Students must check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | |||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | |||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | |||
4. Before inserting the medication vaginally, explain the procedure to the patient. If patient prefers to self-administer the vaginal medication, give specific instructions to patient on correct procedure. | Patient may feel more comfortable self-administering vaginal medication. | |||
5. Ensure that you have water-soluble lubricant available for medication administration. | Lubricant reduces friction against vaginal mucosa as medication is inserted. | |||
6. Have patient void prior to procedure. | Voiding prevents passing of urine during procedure. | |||
7. Raise bed to working height.
| Position helps prevent injury to nurse administering medication. Draping protects patient’s privacy and facilitates relaxation. | |||
8. Apply clean non-sterile gloves. | Gloves protect the nurse from contact with mucous membranes and body fluids. | |||
9. Remove suppository from wrapper and apply a liberal amount of water-soluble lubricant to suppository and index finger of dominant hand. Suppository should be at room temperature. | Lubricant reduces friction against vaginal mucosa as medication is inserted. | |||
10. With non-dominant hand, gently separate labial folds. With gloved index finger of dominant hand, insert lubricated suppository about 8 to 10 cm along posterior vagina wall. | Exposes vaginal orifice and helps to ensure equal distribution of medication. | |||
11. Withdraw finger and wipe away excess lubricant. | Wiping maintains patient comfort. | |||
NOTE: An applicator may be used to insert vaginal medication. Follow procedure above and specific manufacturer directions. | ||||
12. Discard gloves by turning them inside out and disposing of them and any used supplies as per agency policy. Perform hand hygiene. | Using gloves reduces transfer of microorganisms. | |||
13. Document procedure as per agency policy, and include patient’s tolerance of administration. | Timely and accurate documentation promotes patient safety. | |||
Data source: Lilley et al., 2011; Perry et al., 2014 |
Critical Thinking Exercises
The eye is the most sensitive organ to which medication may be applied (Perry et al., 2014). The cornea is especially sensitive, making the conjunctival sac the appropriate site for instilling eye (ophthalmic) medications.
Checklist 48 outlines the steps for instilling eye medications.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS × 3 (must be done with each individual medication):
Medication calculation: D/H × S = A (D or desired dosage/H or have available × S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Before instilling eye medication, offer a tissue to the patient. | Drops may spill from the eye with administration. | ||
5. Wear clean non-sterile gloves. | Using gloves protects the nurse from potential contact with patient body fluids and medications. | ||
6. Cleanse the eyelashes and eyelids of any drainage or crusting with a warm washcloth or gauze. Use each area of cleaning surface only once and move from inner to outer eye area. | Cleansing removes debris from eye area. | ||
7. Tilt patient’s head back slightly if patient is sitting up, or place patient’s head over a pillow (under the neck) if they are lying down. | Tilting the head back makes it easier to reach the conjunctival sac for instilling drops. Do not tilt head back if patient has a cervical spine injury. | ||
8. Invert the eye-drop container and have patient look up and focus on something on the ceiling. | Keeping the eye focused will help keep it still. | ||
9. Gently pull patient’s lower lid down, using thumb or two fingers to expose conjunctival sac. | Place eye drop in conjunctival sac, not directly on eyeball (cornea). | ||
10. Eye drops: Hold eye-drop container above eye, taking care not to touch the eye, eyelids, or eyelashes. Instill one drop or more, if prescribed, into conjunctival sac. Eye ointment: Apply about 1.5 cm of ointment along conjunctival sac, moving from inner to outer canthus. Twist tube to break off ribbon of ointment. | Touching the tip of the container to anything can contaminate the medication. | ||
11. Release lower lid after instillation and ask patient to close eyes gently. Ask patient to move the eyeball while eyes are closed. | This step allows the medication to be distributed across the eye. | ||
12. Eye drops only: apply gentle pressure over inner canthus for 30 to 60 seconds to prevent medication from entering the lacrimal duct. | This minimizes the systemic effects of the medication. | ||
13. Instruct patient not to rub eye. | This is to prevent irritation and injury to the eye. | ||
14. Remove gloves and assist patient to a comfortable and safe position. | This ensures patient safety and comfort. | ||
15. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
16. Document as per agency policy. Include date, time, dose, route; which eye the medication was instilled into; and patient’s response to procedure. | Timely and accurate documentation helps to ensure patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Internal ear structures are particularly sensitive to temperature extremes. Therefore, ear (otic) medications should always be administered at room temperature. Always use sterile ear drops in case the ear drum is ruptured.
Checklist 49 outlines the steps for instilling ear medications.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Before instilling ear drops, don clean non-sterile gloves. | Using gloves protects the nurse from potential contact with patient body fluids and medications. | ||
5. Cleanse external ear of any drainage using a warm wet washcloth. | Drainage or debris may prevent some medication from entering ear canal. | ||
6. Position patient with affected ear uppermost, on unaffected side if lying down, or tilt head to side if sitting up. | Proper positioning helps to stop medication from escaping. Do not tilt head if patient has a cervical spine injury. | ||
7. Draw up medication into ear dropper, ensuring correct dosage. Do not return excess medication to stock bottle. | Risk for contamination is increased if medication is returned to bottle. | ||
8. Gently pull ear pinna back and up for an adult. | Pulling the pinna straightens ear canal. | ||
9. Hold dropper tip just above ear canal. Do not touch dropper tip to ear. | Touching the ear with the dropper tip will contaminate the dropper and the medication. | ||
10. Allow drops to fall on the side of the ear canal. | Dropping the drops directly into the canal and onto the tympanic membrane will cause the patient discomfort. | ||
11. Release ear pinna and have patient remain in the position for at least 5 minutes. | This position prevents medication from escaping from ear. | ||
12. Apply gentle pressure to tragus several times. | Pressure helps move medication toward tympanic membrane. | ||
13. If ordered, a cotton ball may be placed loosely in the ear canal. | Cotton ball helps prevent medication from escaping from ear. | ||
14. Remove gloves and assist patient to a comfortable and safe position. | This ensures patient safety and comfort. | ||
15. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
16. Document as per agency policy. Include date, time, dose, route; which ear the medication was instilled into; and patient’s response to procedure. | Timely and accurate documentation helps to ensure patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Nasal medications are instilled for the treatment of allergies, nasal congestion, and sinus infections. The nose is not a sterile cavity, but medical asepsis must be observed because of its connection to the sinuses.
Checklist 50 outlines the steps for instilling nasal medications.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Before instilling nasal medication, don clean non-sterile gloves. | Using gloves protects the nurse from potential contact with patient body fluids and medications. | ||
5. Provide patient with tissues and ask that they blow their nose. | This clears the nose prior to medication instillation. | ||
6. Position patient sitting back or lying down with head tilted back over a pillow (underneath neck). | This position allows medication to flow back into nasal cavity. Do not tilt head back if patient has a cervical spine injury. | ||
7. Nose drops: draw fluid into medication dropper with enough for both nares. Do not return excess fluid into stock bottle. | Returning fluid to stock bottle increases risk for contamination of medication. | ||
8. Ask patient to breathe through the mouth. Nose drops: hold dropper about 1 cm above naris and drop medication into one naris and then the other. Nasal spray: have patient hold one nostril closed and breathe gently through the other as the spray is being administered. Do not touch the naris with the dropper/spray bottle. | Breathing through the mouth will help prevent aspiration of the medication. Touching the naris with the dropper/spray tip will contaminate the dropper/spray bottle and the medication. | ||
9. Position patient with head back for 2 to 3 minutes. | This position prevents escape of the medication. | ||
10. Remove gloves and assist patient to a comfortable and safe position. | This ensures patient safety and comfort. | ||
11. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
12. Document as per agency policy. Include date, time, dose, route; which naris the medication was instilled into (or whether it was both nares); and patient’s response to procedure. | Timely and accurate documentation helps to ensure patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Critical Thinking Exercises
Medications administered through inhalation are dispersed via an aerosol spray, mist, or powder that patients inhale into their airways. Although the primary effect of inhaled medications is respiratory, there are likely to be systemic effects as well. Most patients taking medication by inhaler have asthma or chronic respiratory disease and should learn how to administer these medications themselves. A variety of inhalers are available, and specific manufacturers’ instructions should always be checked and followed to ensure appropriate dosing.
Nebulization is a process by which medications are added to inspired air and converted into a mist that is then inhaled by the patient into their respiratory system (Lilley et al., 2011; Perry et al., 2014.) (see Figure 6.4). The air droplets are finer than those created by metered dose inhalers, and delivery of the nebulized medication is by face mask or a mouthpiece held between the patient’s teeth.
Checklist 51 outlines the steps for delivering medication through a small-volume nebulizer.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Assemble nebulizer as per manufacturer’s instructions. | Assembly specific to manufacturer’s instructions ensures proper delivery of medication. | ||
5. Add medication as prescribed by pouring medication into the nebulizer cup.
| This step ensures the proper delivery of medication.
| ||
6. Use a mask if patient is unable to tolerate a mouthpiece, and an adaptor specific to tracheostomies if the patient has a tracheostomy. | This ensures the proper delivery of medication. | ||
7. Position patient sitting up in a chair or in bed at greater than 45 degrees. | This position improves lung expansion and medication distribution. | ||
8. Assess pulse, respiratory rate, breath sounds, pulse oximetry, and peak flow measurement (if ordered) before beginning treatment. | Determine a baseline respiratory assessment prior to administration of medication. | ||
NOTE: Attach the nebulizer to compressed air if available; use oxygen if there is no compressed air. If patient is receiving oxygen, do not turn it off. Continue to deliver oxygen through nasal prongs with the nebulizer. | |||
9. Turn on air to nebulizer and ensure that a sufficient mist is visible exiting nebulizer chamber. A flow rate of 6 to 10 L should provide sufficient misting. Ensure that nebulizer chamber containing medication is securely fastened. Ensure that chamber is connected to face mask or mouthpiece, and that nebulizer tubing is connected to compressed air or oxygen flowmeter. | This process verifies that equipment is working properly. | ||
10. If mouthpiece is being used, ensure lips are sealed around mouthpiece. | Sealed lips ensure proper inhalation of medication. | ||
11. Have patient take slow, deep, inspiratory breaths. Encourage a brief 2- to 3-second pause at the end of inspiration, and continue with passive exhalations. Note: If patient is dyspneic, encourage holding every fourth or fifth breath for 5 to 10 seconds. | This maximizes effectiveness of medication. | ||
12. Have patient repeat this breathing pattern until medication is complete and there is no visible misting. This process takes approximately 8 to 10 minutes. | This maximizes the effectiveness of the medication. | ||
13. Tap nebulizer chamber occasionally and at the end of the treatment. | This action releases drops of medication that cling to the side of the chamber. | ||
14. Monitor patient’s pulse rate during treatment, especially if beta-adrenergic bronchodilators are being used. | Beta-adrenergic bronchodilators have cardiac effects that should be monitored during treatment. | ||
15. Once treatment is complete, turn flowmeter off and disconnect nebulizer. | This promotes patient comfort and safety. | ||
16. Rinse, dry, and store nebulizer as per agency policy. | Proper care reduces the transfer of microorganisms. | ||
17. If inhaled medication included steroids, have patient rinse mouth and gargle with warm water after treatment. | Rinsing removes residual medication from mouth and throat, and helps prevent oral candidiasis related to steroid use. | ||
18. Once treatment is complete, encourage patient to perform deep breathing and coughing exercises to help remove expectorate mucous. | Treatments are often prescribed specifically to encourage mucous expectoration. | ||
19. Return patient to a comfortable and safe position. | This promotes patient comfort and safety. | ||
20. Perform hand hygiene. | This step prevents the transfer of microorganisms. | ||
21. Document treatment as per agency policy, and record and report any unusual events or findings to the appropriate health care provider. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
A metered dose inhaler (MDI) is a small handheld device that disperses medication into the airways via an aerosol spray or mist through the activation of a propellant. A measured dose of the drug is delivered with each push of a canister, and dosing is usually achieved with one or two puffs.
Checklist 52 lists the steps for administering medication by MDI.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Assemble MDI as per manufacturer’s instructions. If MDI has not been used for several days, give it a test spray into the air, taking care not to inhale the medication. | Assembly specific to manufacturer’s instructions ensures proper delivery of medication. | ||
5. Ensure that canister is securely inserted into the holder and remove the mouthpiece cover. | This ensures proper delivery of medication. | ||
6. Shake canister well before delivery (5 or 6 shakes). | This ensures proper delivery of medication. | ||
7. Position patient sitting up in a chair or in bed at greater than 45 degrees. | This position improves lung expansion and medication distribution. | ||
8. Assess pulse, respiratory rate, breath sounds, pulse oximetry, and peak flow measurement (if ordered) before beginning treatment. | This determines a baseline respiratory assessment prior to administration of medication. | ||
9. Without spacer:
With spacer:
| This process ensures proper inhalation of medication. | ||
10. Have patient rinse mouth and gargle with warm water about 2 minutes after treatment. | Rinsing removes residual medication from mouth and throat, and helps prevent oral candidiasis related to steroid use. | ||
11. Return patient to a comfortable and safe position. | This promotes patient comfort and safety. | ||
12. Perform hand hygiene. | This step prevents the transfer of microorganisms. | ||
13. Document treatment as per agency policy, and record and report any unusual events or findings to the appropriate health care provider. | Accurate and timely documentation and reporting promote patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Critical Thinking Exercises
In this section, we address how to administer topical medication using three distinct delivery methods: transdermal patch; creams, lotions, or ointments; and powder. Always wear gloves and maintain standard precautions when administering topical medications to the skin, mucous membranes, and tissues. Do not touch any preparations to your own skin, and turn your face away from powdered applications. Always clean the skin or wound before applying a new dose of topical medication.
Checklist 53 lists the steps for applying a transdermal patch.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Med calculation: D/H x S = A (desired dosage/have available x stock = amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Before applying a transdermal patch, remove the old patch if it is still in place. Clean area thoroughly. Observe for signs of skin irritation at old patch and document as per agency policy. | Not removing previous patch may result in overdose of the medication. Check between skin folds for old patch. | ||
5. Dispose of old patch as per agency policy (usually in a biohazard trash bag) by folding in half with sticky sides together and wrapping it in a glove, or cutting it before disposal. | This prevents accidental exposure to the medication. | ||
6. Use a felt tip or soft tip pen to write the date, time, and your initials on the outside of the new patch. DO NOT use a ballpoint pen. | Initialling patch communicates application date and time to other health care providers. Ballpoint pen can damage patch and thus affect medication delivery. | ||
7. Apply the new patch to a new site that is clear, dry, hairless, and free of skin irritations. | If it is necessary to remove hair, clip the hair instead of shaving to avoid skin irritation. A consistent surface ensures even medication distribution. | ||
NOTE: It is usual to have a “patch-free period” of 10 to 12 hours when the patch is removed, because tolerance to the medication may develop if the patch is worn 24 hours/day. Check doctor’s orders to determine if the patch should be removed overnight. | |||
8. Carefully remove the backing from the patch, taking care to hold it at the edges and not touch the medication with your fingers. | This prevents interference with medication and maintains stickiness of patch. | ||
9. Apply patch by holding one hand firmly over the patch for 10 seconds, then press around the edges to make sure that the patch is securely attached to the skin. | This prevents loss of patch and ensures effectiveness of medication delivery. | ||
10. Perform hand hygiene. | This prevents the transfer of microorganisms. | ||
NOTE:
| |||
11. Document as per agency policy, making sure to include site of administration on the MAR. | Accurate and timely documentation improves patient safety. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Checklist 54 lists the steps for applying topical medications as creams, lotions, and ointments.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Apply non-sterile gloves unless skin is broken; then apply sterile gloves. | Using gloves protects health care provider from contact with medication. If skin is broken, sterile gloves will prevent the spread of microorganisms. | ||
5. Wash, rinse, and dry the affected area with water and a clean cloth. | This removes previous topical medications. | ||
6. If skin is very dry and flaking, apply topical medication while skin is still damp. | Applying while skin is damp helps to retain moisture within skin layers. | ||
7. Change gloves, performing hand hygiene in between. | Use sterile gloves for open skin lesions to prevent spread of microorganisms. | ||
8. Place required amount of medication in palm of hands and soften by rubbing palms together. | Softening makes topical medication easier to spread. | ||
9. Let patient know that initial application may feel cold. Apply medication using long even strokes that follow the direction of the hair. Do not rub vigorously. | This prevents irritation of hair follicles. | ||
10. Let patient know that skin may feel greasy after application. | Some topical medications contain oils. | ||
11. Document as per agency policy, making sure to include site of administration on the MAR. | Accurate and timely documentation improves patient safety. | ||
12. Perform hand hygiene. | This step prevents the transfer of microorganisms. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Checklist 55 lists the steps for applying medicinal powder topically.
Checklist 55: Applying Topical PowderDisclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Check MAR against doctor’s orders. | Check that MAR and doctor’s orders are consistent. Night staff usually complete and verify this check as well. | ||
2. Perform the SEVEN RIGHTS x 3 (must be done with each individual medication):
Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared) | The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it. | ||
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
| These checks are done before administering the medication to your patient. If taking drug to bedside (e.g., eye drops), do third check at bedside. | ||
4. Ensure that skin is completely dry and clean before application. | This minimizes potential for powder to cake and crust. | ||
5. If application is near patient’s face, ask patient to turn away from powder or briefly cover face with a clean towel. | This prevents patient from inhaling powder. | ||
6. Dust skin with a light layer of powder. | Too thick a layer of powder will congeal and crust. | ||
7. If ordered, cover the affected site with the prescribed dressing. | Covering site prevents soiling of patient’s clothes and linens. | ||
8. Document as per agency policy, making sure to include site of administration on the MAR. | Accurate and timely documentation improves patient safety. | ||
9. Perform hand hygiene. | Prevents transfer of microorganisms. | ||
Data source: BCIT, 2015; Lilley et al., 2011; Perry et al., 2014 |
Critical Thinking Exercises
Nurses play an essential role in medical reconciliation; preparing, administering, monitoring, evaluating, teaching patients; and documenting responses to medications. Medication administration requires good decision-making skills and clinical judgment, and the nurse is responsible for ensuring full understanding of medication administration and its implications for patient safety.
This chapter discusses guidelines to follow for mitigating medication errors and adverse drug events (ADEs). Non-parenteral routes of medication administration are discussed, and the steps for following each of these processes safely is outlined.
Key Takeaways
Agency for Healthcare Research and Quality. (2014). Checklists. Retrieved on June 11, 2015, from http://psnet.ahrq.gov/primer.aspx?primerID=14
Agrawal, A. (2009). Medication errors: Prevention using information technology systems. Br J Clin Pharmacol, 67(6), 681.
British Columbia Institute of Technology (BCIT). (2015). NURS 1020: Clinical techniques. Vancouver: British Columbia Institute of Technology (BCIT).
Butt, A.R. (2010). Medical error in Canada. Issues related to reporting medical error and methods to increase reporting. McMasters Univserity Medical Journal, Clinical Review, 7(1). 15 – 8. Retrieved on June 3, 2015 from http://www.mumj.org/Issues/v7_2010/articles/16.pdf
Canadian Patient Safety Institute. (2012). Canadian incident analysis framework. Retrieved on Nov 14, 2015, from http://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF#search=canadian%20analysis%20incident%20framework
Centers for Disease Control. (2013). Infection control. Retrieved on June 11, 2015, from http://www.cdc.gov/oralhealth/infectioncontrol/faq/protective_equipment.htm
Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses’ workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13, 175. doi:10.1186/1472-6963-13-175
Institute for Healthcare Improvement. (2015). High alert medication safety. Retrieved on June 11, 2015, from http://www.ihi.org/topics/highalertmedicationsafety/pages/default.aspx
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (eds). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
Lilley, L. L., Harrington, S., Snyder, J. S., & Swart, B. (2011). Pharmacology for Canadian health care practice (2nd ed.). Toronto, ON: Elsevier Canada.
Lowry, M. (2016). Rectal drug administration in adults: How, when, why. Nursing Times, 112(8), 12-14. Retrieved from https://www.nursingtimes.net/clinical-archive/neurology/rectal-drug-administration-in-adults-how-when-why/7002595.article
Lynn, P. (2011). Photo atlas of medication administration (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
National Patient Safety Agency. (2009). Safety in doses. Improving the use of medication in NHS. Retrieved on June 11, 2015, from http://www.nrls.npsa.nhs.uk/resources/?entryid45=61625
National Priority Partnership. (2010). Preventing medical errors: A $21 billion opportunity. Retrieved on June 3, 2015, from http://psnet.ahrq.gov/resource.aspx?resourceID=20529
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.
Poon, E. G. et al. (2010). Effect of bar-code technology on the safety of medication administration. N Engl J Med., 362, 1698.
Prakash, V., Koczmara, C., Saveage, P., Trip, K., Stewart, J., Mccurdie, T., Cafazzo, J., & Trbovich, P. (2014). Mitigating errors caused by interruptions during medication verification and administration: Interventions in a simulated ambulatory chemotherapy setting. BMJ Quality and Safety, 0 (1 – 10). doi:10.1136/bmjqs-2013-002484
The Joint Commission (TJC). (2012). National patient safety goals. Oakbrook Terrace, IL: The Commission. Retrieved on June 3, 2015, from http://www.jointcommission.org/standards_information/npsgs.aspx
Vancouver Coastal Health. (2014). Course catalogue registration system. Retrieved from Medication Reconciliation: Top Ten Tips, https://bcpsqc.ca//documents/2012/09/Top-10-Tips-for-Interviewing-Patients.pdf
Parenteral medications are medications administered directly into body tissue or the circulatory system (according to Merriam-Webster, “parenteral” is a term taken from the Greeks meaning “to avoid the intestines”). They are synonymous with “injectables,” as syringes and needles are used to administer these medications by subcutaneous, intradermal, intramuscular, and intravenous routes. Injections are a direct and reliable way to deliver medication for fast absorption. However, parenteral medications pose a greater risk of harm and adverse reactions than nonparenteral medications. Parenteral medications require special equipment and a specific skill set to ensure that the medication is prepared correctly to have the right therapeutic effect, and to avoid complications (Perry, Potter, & Ostendorf, 2014).
Learning Objectives
Parenteral refers to the path by which medication comes in contact with the body. Parenteral medications enter the body by injection through the tissue and circulatory system. Injection medications are absorbed more quickly and are used with patients who are nauseated, vomiting, restricted from taking oral fluids, or unable to swallow. Parenteral medications can be effective and safe when prepared and administered correctly. However, because they are invasive and absorbed readily and quickly into the body, there are numerous risks associated with administering them (Perry et al., 2014).
There are four routes for parenteral medications (also see Figure 7.1). Each type of injection requires a specific skill set to ensure the medication is prepared properly and administered into the correct location (Perry et al., 2014). The four types of injections are:
To administer parenteral medications safely, it is imperative to understand how to prevent an infection, prevent medication errors, prevent a needle-stick injury, and prevent discomfort to the patient. Tables 7.1 to 7.4 address specific practices to eliminate safety hazards to patients and health care workers.
According to Seigel et al, (2007), research has shown that unsafe injection practices have resulted in patient exposure to infections leading to outbreaks of infectious diseases. These unnecessary exposures were the result of deficient health care practices. Injectable medications must be given in a safe manner to maintain sterility of equipment and prevent the transmission of infectious diseases between patients and health care workers. Table 7.1 summarizes how to prevent an infection during an injection.
Safety consideration:
| |||
Principle | Additional Information | ||
Perform hand hygiene. | Always perform hand hygiene before administration and after removing gloves. For hand hygiene with ABHR, use 1 to 2 pumps of product; this volume requires a minimum of 15 seconds for hands to dry. | ||
Prevent needle/syringe contamination. | Keep sterile parts of the needle and syringe sterile. Avoid letting the needle touch unsterile surfaces such as the outer edges of the ampule or vial, surface of the needle cap, or counter. Always keep the needle covered with a cap when not in use, and use the scoop-cap method to avoid needle-stick injuries. Avoid touching the length of the plunger. Keep the tip of the syringe sterile by covering with a cap or needle. | ||
Prepare patient’s skin. | Wash the patient’s skin with soap and water when it is soiled with dirt, drainage, or fecal matter/urine. Follow agency policy for skin preparation. When using an alcohol swab, use a circular motion to rub the area for 15 seconds, and then let the area dry for 30 seconds. If cleaning a site, move from the centre of the site outward in a 5 cm (2 in.) radius. | ||
Prevent contamination of solution. | Use single-dose vials/ampules whenever possible. Do not keep multi-dose vials in patient treatment area. Discard if sterility is compromised or questionable. Do not combine and administer medications from single-dose vials or ampules for later use. Ampules should not sit open and should be used immediately, then discarded appropriately. | ||
Use new, sterile sterile equipment with each injection. | Single use syringe and needle must be used with each patient. Always inspect packaging for intactness; inspect for dryness, rips, torn corners and expiry date. If single use equipment is not available, use syringes and needles designed for steam sterilization. | ||
Data source: CDC, 2015; Hutin et al., 2003; Perry et al., 2014; Provincial Infectious Disease Advisory Committee, 2014; Siegel et al., 2007. |
Medication errors have a substantial impact on health care in Canada (Butt, 2010). When preparing and administering medication, and assessing patients after receiving medication, always follow agency policy to ensure safe practice. Review Table 7.2 for guidelines for safe medication administration.
Safety consideration:
| |||
Principle | Additional Information | ||
Be vigilant when preparing medications. | Avoid distractions. Some agencies have a no-interruption zone (NIZ), where health care providers can prepare medications without interruptions. | ||
Check for allergies. | Always ask patient about allergies, types of reactions, and severity of reactions. | ||
Use two patient identifiers at all times. Always follow agency policy for patient identification. | Use at least two patient identifiers before administration AND compare against the medication administration record (MAR). | ||
Assessment comes before medication administration. | All medications require an assessment (review of lab values, pain, respiratory or cardiac assessment, etc.) prior to medication administration to ensure the patient is receiving the correct medication for the correct reason. | ||
Be diligent in all medication calculations. | Errors in medication calculations have contributed to dosage errors, especially when adjusting or titrating dosages. | ||
Avoid reliance on memory; use checklists and memory aids. | Slips in memory are caused by lack of attention, fatigue, and distractions. Mistakes are often referred to as attentional behaviours, and they account for most errors in health care. If possible, follow a standard list of steps for every patient. | ||
Communicate with your patient before and after administration. | Provide information to patient about the medication before administering it. Answer questions regarding usage, dose, and special considerations. Give the patient the opportunity to ask questions. Include family members if appropriate. | ||
Avoid workarounds. | A workaround is a process that bypasses a procedure, policy, or problem in a system. For example, nurses may “borrow” a medication from another patient while waiting for an order to be filled by the pharmacy. These workarounds fail to follow agency policies that ensure safe medication practices. | ||
Ensure medication has not expired. | Medication may be inactive if expired. | ||
Always clarify an order or procedure that is unclear. | Always ask for help whenever you are uncertain or unclear about an order. Consult with the pharmacist, charge nurse, or other health care providers and be sure to resolve all questions before proceeding with medication administration. | ||
Use available technology to administer medications. | Bar-code scanning (eMAR) has decreased errors in administration by 51%, and computerized physician orders have decreased errors by 81%. Technology has the potential to help decrease errors. Use technology when administering medications, but be aware of technology-induced errors. | ||
Report all near misses, errors, and adverse reactions. | Reporting allows for analysis and identification of potential errors, which can lead to improvements and sharing of information for safer patient care. | ||
Be alert to error-prone situations and high-alert medications. | High-alert medications are those that are most likely to cause significant harm, even when used as intended. The most common high-alert medications are anticoagulants, narcotics and opiates, insulins, and sedatives. The types of harm most commonly associated with these medications include hypotension, respiratory depression, delirium, bleeding, hypoglycemia, bradycardia, and lethargy. | ||
If a patient questions or expresses concern regarding a medication, stop and do not administer it. | If a patient questions a medication, stop and explore the patient’s concerns, review the physician’s order, and, if necessary, notify the practitioner in charge of the patient. | ||
Data source: Agency for Healthcare Research and Quality, 2014; Canadian Patient Safety Institute, 2012; Debono et al., 2013; Institute for Healthcare Improvement, 2015; National Patient Safety Agency, 2009; National Priority Partnership, 2010; Prakash, et al., 2014 |
Injections can be given safely and effectively, and harm can be prevented if proper injection technique is used. Most complications related to injections are associated with intramuscular injections, but may occur with any route. Complications can occur when an incorrect site is used, or with an inappropriate depth or rate of injection (Malkin, 2008). To promote patient safety and comfort during an injection, review the guidelines in Table 7.3.
Principle | Additional Information | ||
Correct needle | For injections, use a sharp, beveled needle and place bevel side up. Change the needle if liquid coats the shaft of the needle. Correct needle length allows for correct delivery of medication into the correct site and can reduce complications such as abscesses, pain, and bruising. Needle selection should be based on size of patient, gender, injection site, and amount of medication injected. Women tend to have more adipose tissue around the buttocks and deltoid fat pad, which means more than half the injections given do not reach the proper IM depths in women. Large bore needles have been found to reduce pain, swelling, and redness after an injection, as less pressure is required to depress the plunger. | ||
Proper angle of insertion and removal (see Figure 7.1) | Inserting the needle at the proper angle (depending on the type of injection) and entering the skin smoothly and quickly can reduce pain during injection. Hold the syringe steady once the needle is in the tissue to prevent tissue damage. Withdraw the needle at the same angle used for insertion. The angle for an IM injection is 90 degrees. With all injections, the needle should be inserted all the way up to the hub. Holding the syringe like a dart prevents the medication from being injected during insertion of needle. Removing residue (medication on the tip of the needle) has been shown to reduce pain and discomfort. To remove residue from the needle, change needles after preparation and before administration. | ||
Patient position | The patient’s position may affect their perception of pain. Proper position will also facilitate proper landmarking of the site. For IM injections, for example, the ventrogluteal site has the greatest muscle thickness and is free of nerves and blood vessels, with a small layer of fat. | ||
Relaxation technique and distraction methods | Position the patient’s limbs in a relaxed, comfortable position to reduce muscle tension. For example, lying prone may help a patient relax prior to an IM injection. If giving a deltoid IM injection, have the patient relax the arm by placing the hand in the lap. If a patient is receiving an IM injection in the vastus lateralis or ventrogluteal site, encourage the patient to gently point toes outwards to relax the muscle. Relaxation skills of the health care provider will help decrease the patient’s anxiety-heightened pain. If possible, divert the patient’s attention away from the injection procedure. | ||
Pre-medication, if required | To decrease pain upon insertion, a vapocoolant spray, topical anesthetic, or wrapped ice may be placed on the insertion site for a minute prior to injection. For IM injections, two studies found that applying pressure to the injection site for 10 seconds before the injection reduced pain. This data supports the gate theory of pain control. | ||
Z-track method for IM injections | Some research shows that the Z-track technique results in reduced pain and complications, and fewer injection lesions. However, other research shows that Z-track injections result in more pain and bleeding at the injection site. (See 7.4 Intramuscular Injections for more on the Z-track method.) | ||
Administration rate | Research has found that administrating medications at 10 seconds per ml is an effective rate for IM injections. Increasing the rate to 20 seconds per ml did not show any reduction in pain. Always review drug administration rate as per pharmacy or manufacturer’s recommendations. | ||
Gentle touch with insertion sites | Gently apply a dry sterile gauze to the site after the injection. Rotate injection sites to prevent the development of indurations and abscesses. | ||
Aspiration with IM injections | Review the latest research regarding the utility of aspirating IM injections. There is lack of strong evidence to support the technique of aspiration with IM injections. | ||
Data source: Ağac & Günes, 2011; Canadian Agency for Drugs and Technologies in Health, 2014; Cocoman & Murray, 2008; Greenway, 2014; Hunter, 2008; Malkin, 2008; Mitchell & Whitney, 2001; Nisbit, 2006; Ogston-Tuck, 2014a; Perry et al., 2014; Rodgers & King, 2000; Sisson, 2015; Workman, 1999 |
Health care providers can be at risk for needle-stick injuries in any health care setting. The most common places for needle-stick injuries to occur are in the operating room and patient rooms. Tasks that place the health care provider at risk include recapping needles and mishandling IV lines. Table 7.4 provides guidelines to prevent needle-stick injuries.
Principle | Additional Information | ||
Avoid recapping needles. | Recapping needles has led to the transmission of infection. If possible, always use devices with safety features — i.e., safety shield. | ||
Dispose of the needle immediately after injection. | Immediately dispose of used needles in a sharps disposal container (puncture-proof and leak-proof) to avoid unsafe disposal of a sharp. | ||
Reduce or eliminate all hazards related to needles. | Avoid using needles if possible. Use a needle only when performing an SC, ID, or IM injection. Use a needleless system and engineered safety devices for prevention of needle-stick injuries. | ||
Plan disposal of sharps before injection. | Plan the safe handling and disposal of needles before beginning a procedure that requires a sharp needle. Bring sharps container close to the bedside prior to injection. Sharps containers should be at eye level and within arm’s reach. | ||
Follow all standard policies related to prevention / treatment of injury. | Follow all agency policies regarding infection control, hand hygiene, standard and additional precautions, and blood and body fluid exposure management. | ||
Report all injuries. | Report all needle-stick injuries and sharp-related injuries immediately. Data collected regarding the nature of injuries help guide needle-stick prevention strategies for new practices and devices. Review how to manage needle-stick injuries and follow agency policy regarding exposure to blood-borne pathogens. Policies help decrease the risk of contracting a blood-borne illness. | ||
Participate in required training and education. | Attend training on injury-prevention strategies related to needles and safety devices as per agency policy. Participate in and evaluate the selection of safety devices, and report known needle-stick hazards to managers. | ||
Data source: American Nurses Association, 2002; Centers for Disease Control, 2012; National Institute for Occupational Safety and Health, 1999; Perry et al., 2014; Pratt et al., 2007; Wilburn, 2004; Wilburn & Eijkemans, 2004 |
Specific equipment, such as syringes and needles, is required to prepare and administer parenteral medications. The selection of the syringe and needle is based on the type and location of injection; amount, quality, and type of medication; and the body size of the patient. Many syringes come with needleless systems or needles with safety shields to prevent injuries (Perry et al., 2014). Aseptic technique is paramount to the preparation and administration of these medications.
Parenteral medications are supplied in sterile vials, ampules, and prefilled syringes. Ampules are glass containers in 1 ml to 10 ml sizes that hold a single dose of medication in liquid form. They are made of glass and have a scored neck to indicate where to break the ampule (see Figure 7.2). Medication is withdrawn using a syringe and a filter needle. A blunt fill needle with filter (see Figure 7.3) must be used when withdrawing medication to prevent glass particles from being drawn up into the syringe (see Figure 7.4). Never use a filter needle to inject medication (Perry et al., 2014).
A vial is a single- or multi-dose plastic container with a rubber seal top, covered by a metal or plastic cap (see Figure 7.5). A single-use vial must be discarded after one use; a multi-dose vial must be labelled with the date it was opened. Check hospital policy to see how long an open vial may be used. The vial is a closed system, and air must be injected into the vial to permit the removal of the solution (Perry et al., 2014) (see Figure 7.6).
A syringe (see Figure 7.7)is a sterile, single-use device that has a Luer lock (see Figure 7.8) or non-Luer lock tip, which influences the name of the syringe. Syringes come in various sizes from 0.5 ml to 60 ml. Syringes may come with or without a sterile needle and will have a safety shield on the needle.
Insulin is only given using an insulin syringe (see Figure 7.9). Insulin is ordered in units. It is important to use the correct syringe and needle for the specific injection. Always examine the measurement scale on the syringe to determine that you have the correct syringe (Lynn, 2011).
Needles are made of stainless steel, are sterile and disposable, and come in various lengths and sizes. The needle is made up of the hub, shaft, and bevel. The bevel is the tip of the needle that is slanted to create a slit into the skin. The hub fits onto the tip of the syringe. All three parts must remain sterile at all times. The length of the needle will vary from 1/8 in. to 3 in., depending on the injection. The gauge of a needle is the diameter of the needle. Gauges can vary from very small diameter (25 to 29 gauge) to large diameter (18 to 22 gauge). A needle will have its gauge and length marked on the outer packaging; choose the correct gauge and length for the injection ordered (Lynn, 2011) (see Figures 7.10, 7.11, and 7.12).
Critical Thinking Exercises
Intradermal injections (ID) are injections administered into the dermis, just below the epidermis. The ID injection route has the longest absorption time of all parenteral routes. These types of injections are used for sensitivity tests, such as TB (see Figure 7.13), allergy, and local anesthesia tests. The advantage of these tests is that the body reaction is easy to visualize, and the degree of reaction can be assessed. The most common sites used are the inner surface of the forearm and the upper back, under the scapula. Choose an injection site that is free from lesions, rashes, moles, or scars, which may alter the visual inspection of the test results (Lynn, 2011).
Equipment used for ID injections is a tuberculin syringe calibrated in tenths and hundredths of a millilitre, and a 1/4 to 1/2 in., 26 or 27 gauge needle. The dosage of an ID injection is usually under 0.5 ml. The angle of administration for an ID injection is 5 to 15 degrees. Once the ID injection is completed, a bleb (small blister) should appear under the skin. Checklist 56 outlines the steps to administer an intradermal injection.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | ||||
Safety Considerations:
| ||||
Steps | Additional Information | |||
1. Prepare medication or solution as per agency policy. Ensure all medication is properly identified. Check physician orders, Parenteral Drug Therapy Manual (PDTM), and MAR to validate medication order and guidelines for administration. | Properly identifying medication decreases risk of inadvertently administering the wrong medication. Preparing medications ensures patient safety with medication administration. | |||
2. Perform hand hygiene. | Gather all supplies: medication syringe, non-sterile gloves, alcohol swab and sterile gauze, Band-Aid (if required). | |||
3. Enter room and introduce yourself, explain procedure and the medication, and allow patient time to ask questions. | Explaining rationale increases the patient’s knowledge and reduces their anxiety. | |||
4. Close the door or pull the bedside curtains. | This provides patient privacy. | |||
5. Compare MAR to patient wristband and verify this is the correct patient using two identifiers. | This ensures accuracy of the medication or solution and prevents errors. Two patient identifiers are patient name and date of birth. | |||
6. Assess patient for any contraindications to the medications. | Assessment is a prerequisite for every medication given. | |||
7. Select appropriate site for administration. Assist the patient to the appropriate position as required. | Site should be free from lesions, rashes, and moles. Selecting the correct site allows for accurate reading of the test site at the appropriate time. | |||
8. Perform hand hygiene and apply non-sterile gloves. | Gloves help prevent exposure to contaminants. | |||
9. Clean the site with an alcohol swab or antiseptic swab. Use a firm, circular motion. Allow the site to dry. | Pathogens from the skin can be forced into the tissues by the needle. Allowing the skin to dry prevents introducing alcohol into the tissue, which can be irritating and uncomfortable. | |||
10. Remove needle from cap by pulling it off in a straight motion. | This decreases risk of accidental needle-stick injury. | |||
11. Using non-dominant hand, spread the skin taut over the injection site. | Taut skin provides easy entrance for the needle. | |||
12. Hold the syringe in the dominant hand between the thumb and forefinger, with the bevel of the needle up. | This allows for easy handling of the syringe. | |||
13. Hold syringe at a 5- to 15-degree angle from the site. Place the needle almost flat against the patient’s skin, bevel side up, and insert needle into the skin. Insert the needle only about 1/4 in., with the entire bevel under the skin. | Keeping the bevel side up allows for smooth piercing of the skin and induction of the medication into the dermis. | |||
14. Once syringe is in place, slowly inject the solution while watching for a small weal or bleb to appear. | The presence of the weal or bleb indicates that the medication is in the dermis. | |||
15. Withdraw the needle at the same angle as insertion, engage safety shield or needle guard, and discard in a sharps container. Do not massage area after injection. | Withdrawing at the same angle as insertion minimizes discomfort to the patient and damage to the tissue. Proper needle disposal prevents needle-stick injuries. Massaging the area may spread the solution to the underlying subcutaneous tissue. Gently pat with sterile gauze if blood is present. | |||
16. If injection is a TB skin test, circle the area around the injection site to allow for easy identification of site in three days. | ||||
17. Discard remaining supplies, remove gloves, and perform hand hygiene | This prevents the spread of microorganisms. | |||
18. Document the procedure and findings according to agency policy. | Proper documentation helps ensure patient safety. Document time, date, location, and type of medication injected. | |||
19. Evaluate the patient response to injection within appropriate time frame. | The patient will need to be evaluated for therapeutic and adverse effects of the medication or solution. | |||
Data source: ATI, 2015a; Berman & Snyder, 2016; Brookside Associates, 2015a; Clayton, Stock, & Cooper, 2010; Perry et al., 2014 |
Subcutaneous (SC) injections are administered into the adipose tissue layer just below the epidermis and dermis. This tissue has few blood vessels, so drugs administered by this route have a slow, sustained rate of absorption. Sites for SC injections include the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crest) within one inch of the belly button, anterior aspects of the thighs, upper back, and upper ventral gluteal area (Lynn, 2011) (see Figure 7.14).
Choose a site that is free of skin lesions and bony prominences. Site rotation prevents the formation of lipohypertrophy or lipoatrophy in the skin. Physical exercise or application of hot or cold compresses influences the rate of drug absorption by altering local blood flow to the tissues. Any condition that impairs that blood flow to the subcutaneous tissue contradicts the use of subcutaneous injections. Examples of subcutaneous medications include insulin, opioids, heparin, epinephrine, and allergy medication (Perry et al., 2014).
To administer an SC injection, a 25 to 30 gauge, 3/8 in. to 5/8 in. needle is used. Some subcutaneous injections come prefilled with the syringe attached. Always confirm that the right-size needle is appropriate for the patient before use. Subcutaneous injections are usually given at a 45- to 90-degree angle. The angle is based on the amount of subcutaneous tissue present. Generally, give shorter needles at a 90-degree angle and longer needles at a 45-degree angle (Lynn, 2011). SC injections do not need to be aspirated as the likelihood of injecting into a blood vessel is small. Usually, no more than 1 ml of medication is given subcutaneously, as larger amounts may cause discomfort to the patient and may not be absorbed appropriately (Lynn, 2011).
There are varying opinions on whether to pinch the skin during administration. Pinching is advised for thinner patients in order to lift the adipose tissue up and away from the underlying muscle and tissue. If pinching is used, release the pinch when the needle is inserted to avoid injecting into compressed tissue. Note, too, that elevating or pinching the skin has been found to increase the risk of injury, as the needle may pierce the opposite side of the skin fold and enter the skin of the health care worker (Black, 2013). The abdomen is the best location for an SC injection if a patient has little peripheral SC tissue. If patient is obese, use a needle that is long enough to insert through the tissue at the base of the skin fold (Perry et al., 2014).
Insulin is considered a high-risk medication, and special care must be taken to ensure the correct amount of medication and type of insulin is administered at the correct time. As well, safety checks related to a patient receiving SC insulin should be carried out (Ellis & Parush, 2012). Table 7.5 lists specific guidelines for administering insulin (and see Figure 7.15).
Insulin | Additional Information | ||
Insulin is considered a high-risk medication. | Special care must be taken to ensure the correct amount of medication and type of insulin is administered, at the correct time. It is highly recommended to always get your insulin dosages double-checked by another health care provider. Always follow the standard for medication preparation at your agency. | ||
Insulin is only administered using an insulin syringe. | Insulin is the only drug with its own type of syringe with a needle attached. Insulin is always ordered and administered in units, based on a blood sugar reading and a diabetic insulin protocol (or sliding scale). Some hospitals have preprinted physician orders, and some hospitals have handwritten orders. Insulin syringes can come in 30-, 50-, or 100-unit measurements. Always read the increments (calibration) carefully. | ||
There are different types of insulin. | There are rapid-, short-, intermediate-, and long-acting insulins. For each type of insulin, it is important to know how the insulin works and the onset, peak, and duration of the insulin. | ||
Administering two different types of Insulin. | If a patient is ordered two types of insulin, some insulins may be mixed together in one syringe. Many insulins MAY NOT be mixed together. Do not mix Lantus (Glargine) or Levemir (Determir).If administering cloudy insulin preparations (Humulin – N), gently roll the vial between the palms of your hands to re-suspend the medication. Always draw up the short acting insulin first, to prevent it from being contaminated with the long acting. If too much insulin is drawn up from the second vial, discard syringe and start again. Always check with the PDTM for the most current guidelines regarding insulin administration.Insulin orders may change from day to day. Always ensure the most current physician orders are being followed. | ||
Know about rotating injection sites. | Injection site rotation is no longer necessary as newer insulins have a lower risk for hypertrophy of the skin. Typically, a patient will pick one anatomic area (e.g., upper arm) and rotate the injection sites within that region to maintain consistent insulin absorption from day to day. Insulin absorption rates vary from site to site. The abdomen absorbs the fastest, followed by the arms, thighs, and buttocks. | ||
Know when to administer insulin. | The timing of insulin injections is critical to correct insulin administration based on blood sugar levels and when the patient will eat. Knowing the peak action and duration of insulin is critical to proper insulin medication management. If giving insulin, always ensure the patient is not nauseated, is able to eat, and that food is arriving before the insulin starts working. Typically, short- or rapid-acting insulin is given 15 minutes before meals. Intermediate- or long-acting insulin may be given twice daily, at breakfast and dinner. | ||
Measure blood sugar levels and food intake. | Insulin injections are based on blood sugar values and on when the patient will eat. The timing of an insulin injection is critical to ensure the patient receives insulin correctly. | ||
Use insulin injection pens. | Injection pens are a new technology used by patients to self-inject insulin using a syringe, needle, and prefilled cartridge of insulin. It is essential that patients be taught how to use injection pens so they understand the technology. A mini-infusion pump is a battery-operated machine that delivers medications in very small amounts to patients with controlled infusion times. The most common types of mini-infusion sets are insulin pumps or subcutaneous infusion devices. For more information on mini-infusion sets and volume-controlled sets, see Suggested Online Resources in section 7.8. | ||
Data source: Canadian Diabetes Association, 2013; Perry et al., 2014 |
Heparin is an anticoagulant used to reduce the risk of thrombosis formation by suppressing clot formation (Perry et al., 2014). Heparin is also considered a high-alert medication (ISMP, 2014).
Table 7.6 provides specific guidelines to consider before and after administering heparin.
Heparin | Additional Information | ||
Heparin is considered a high-risk medication. | Heparin is available in vials and prefilled syringes in a variety of concentrations. Because of the dangerous adverse effects of the medication, it is considered a high-risk medication. Always follow agency policy regarding the preparation and administration of heparin. | ||
Rotate heparin injection sites. | It is important to rotate heparin sites to avoid bruising in one location. To minimize bruising and pain associated with heparin injections, they can be given in the abdominal area, at least 5 cm away from the belly button. | ||
Know the risks associated with heparin. | There are many risks associated with the administration of heparin, including bleeding, hematuria, hematemesis, bleeding gums, and melena. | ||
Review lab values. | Review lab values (PTT and aPTT) before and after heparin administration. | ||
Use prepackaged heparin syringes. | Many agencies use prepackaged heparin syringes. Always follow the standards for safe medication administration when using prefilled syringes. Low molecular weight heparin (LMWH) is more effective in some patients. | ||
Assess patient conditions prior to administration. | Some conditions increase the risk for hemorrhage (bleeding), such as recent childbirth, severe diabetes, severe kidney and liver disease, severe traumas, cerebral or aortic aneurysm, cerebral vascular accidents (CVA), blood dyscrasias, and severe hypotension. | ||
Assess medications prior to administration. | Over-the-counter (OTC) herbal medications, such as garlic, ginger, and horse chestnut, may interact with heparin. Additional medications that may interact include Aspirin, NSAIDS, cephalosporins, anti-thyroid agents, thrombolytics, and probenecids. | ||
Data source: Clayton et al., 2010; Ogston-Tuck, 2014b; Perry et al., 2014 |
Checklist 57 provides the steps to complete a subcutaneous injection.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
1. Prepare medication or solution as per agency policy. Always compare the physician orders with the MAR. | Preparing medications ensures patient safety with medication administration. | ||
2. Perform hand hygiene; gather supplies. | You will need medication syringe, non-sterile gloves, alcohol swab and sterile gauze, Band-Aid. | ||
3. Enter room and introduce yourself. Identify patient using two acceptable identifiers, explain procedure and the medication, and allow patient time to ask questions. | Explaining rationale increases the patient’s knowledge and reduces their anxiety. | ||
4. Close the door or pull the bedside curtains. | This provides patient privacy. | ||
5. Compare MAR to patient wristband and verify this is the correct patient using two identifiers. | This ensures accuracy of the medication or solution and prevents errors. | ||
6. Assess patient for any contraindications for the medications. | Assessment is a prerequisite to the administration of medications. | ||
7. Put on non-sterile gloves. | Gloves help prevent exposure to contaminants. | ||
8. Select appropriate site for administration. Assist the patient to the appropriate position as required. | Site should be free from lesions, rashes, and moles. Choosing the correct site allows for accurate reading of the test site at the appropriate time. | ||
9. Clean the site with an alcohol swab or antiseptic swab. Use a firm, circular motion. Allow the site to dry. | Pathogens from the skin can be forced into the tissues by the needle. Allowing the skin to dry prevents introducing alcohol into the tissue, which can be irritating and uncomfortable. | ||
10. Remove the needle cap with the non-dominant hand, pulling it straight off. | This technique lessens the risk of an accidental needle-stick injury. | ||
11. Grasp or pinch the area surrounding the injection site, or spread the skin taut at the site. | The decision to create a skin fold is based on the nurse’s assessment of the patient and the needle length used. Pinching is advised for thinner patients. | ||
12. Hold the syringe in the dominant hand between the thumb and forefinger. Insert the needle quickly at a 45- to 90-degree angle. | Inserting quickly causes less pain to the patient. Subcutaneous tissue is abundant in well-nourished, well-hydrated people. For patients with little subcutaneous tissue, it is best to insert the needle at a 45-degree angle. | ||
13. After the needle is in place, release the tissue. Move your non-dominant hand to steady and lower the end of the needle. With your dominant hand, inject the medication at a rate of 10 seconds per ml. Avoid moving the syringe. | Keeping the needle steady helps keep the needle in place. | ||
14. Withdraw the needle quickly at the same angle at which it was inserted, while supporting the surrounding tissue with your non-dominant hand. | Withdrawing at the same angle prevents tissue damage and increased pain at the injection site. | ||
15. Using a sterile gauze, apply gentle pressure at the site after the needle is withdrawn. Do not massage the site. | Massage is not necessary and can damage underlying tissue. Massaging after a heparin injection can contribute to the formation of a hematoma. | ||
16. Do not recap the needle. Apply the safety shield or needle guard on needle and dispose in a sharps container. | Safety shields and needle guards help prevent accidental needle-stick injuries. | ||
17. Dispose of supplies; remove gloves and perform hand hygiene. | This reduces the risk of infection and the spread of microorganisms. | ||
18. Document procedure and findings according to agency policy. | Timely documentation ensures patient safety. | ||
19. Evaluate patient response to medication. | It is important to evaluate the therapeutic effect of the medication and assess for adverse effects. | ||
Data source: ATI, 2015b; Berman & Snyder, 2016; Brookside Associates, 2015b; Clayton et al., 2010; National Institute of Health Clinical Center, 2015; Ogston-Tuck, 2014b; Perry et al., 2014 |
Critical Thinking Exercises
Intramuscular (IM) injections deposit medications into the muscle fascia, which has a rich blood supply, allowing medications to be absorbed faster through muscle fibres than they are through the subcutaneous route (Malkin, 2008; Ogston-Tuck, 2014a; Perry et al., 2014). The IM site is used for medications that require a quick absorption rate but also a reasonably prolonged action (Rodgers & King, 2000). Due to their rich blood supply, IM injection sites can absorb larger volumes of solution, which means a range of medications, such as sedatives, anti-emetics, hormonal therapies, analgesics, and immunizations, can be administered intramuscularly in the community and acute care setting (Hunter, 2008; Ogston-Tuck, 2014a). In addition, muscle tissue is less sensitive than subcutaneous tissue to irritating solutions and concentrated and viscous medications (Greenway, 2014; Perry et al., 2014; Rodgers & King, 2000).
The technique of IM injections has changed over the past years due to evidence-based research and changes in equipment available for the procedure. An IM site is chosen based on the age and condition of the patient and the volume and type of medication injected. When choosing a needle size, the weight of the patient, age, amount of adipose tissue, medication viscosity, and injection site all influence the needle selection (Hunter, 2008; Perry et al., 2014; Workman, 1999).
Intramuscular injections must be done carefully to avoid complications. Complications with IM include muscle atrophy, injury to bone, cellulitis, sterile abscesses, pain, and nerve injury (Hunter, 2008; Ogston-Tuck, 2014a). With IMs, there is an increased risk of injecting the medication directly into the patient’s bloodstream. In addition, any factors that impair blood flow to the local tissue will affect the rate and extent of drug absorption. Because of the adverse and documented effects of pain associated with IM injections, always use this route of administration as a last alternative; consider other methods first (Perry et al., 2014).
Sites for intramuscular injections include the ventrogluteal, vastus lateralis, and the deltoid site. Literature shows inconsistency in the selection of sites for deep muscular injections: selection may be based on familiarity and confidence rather than on “best practice” (Ogston-Tuck, 2014a). However, there is sufficient evidence that the ventrogluteal IM site is the preferred site whenever possible, and is an acceptable site for oily and irritating medications. The ventrogluteal site is free from blood vessels and nerves, and has the greatest thickness of muscle when compared to other sites (Cocoman & Murray, 2008; Malkin, 2008; Ogston-Tuck, 2014a). A longer needle with a larger gauge is required to penetrate deep muscle tissue. The needle is inserted at a 90-degree angle perpendicular to the patient’s body, or at as close to a 90-degree angle as possible. Use a quick, darting motion when inserting the needle.
Aspiration refers to the action of pulling back on the plunger for 5 seconds prior to injecting medication (Ipp, Sam, & Parkin, 2006). Current practice in the acute care setting is to aspirate IM injections to check for blood return in the syringe. Lack of blood in the syringe confirms that the needle is in the muscle and not in a blood vessel. If blood is aspirated, remove the needle, discard it appropriately, and re-prepare and administer the medications (Perry et al., 2014). Recent research has found that there is no evidence to support the practice of aspiration, but despite policy changes, the procedure of aspiration continues to be taught and practised (Canadian Agency for Drugs and Technologies in Health, 2014; Greenway, 2014; Sepah, Samad, & Altaf, 2014; Sisson, 2015). Vaccinations and immunizations given by IM injections are never aspirated (Centers for Disease Control, 2015).
The Z-track method is a method of administrating an IM injection that prevents the medication being tracked through the subcutaneous tissue, sealing the medication in the muscle, and minimizing irritation from the medication. Using the Z-track technique, the skin is pulled laterally, away from the injection site, before the injection; then the medication is injected, the needle is withdrawn, and the skin is released. This method can be used if the overlying tissue can be displaced (Lynn, 2011).
Table 7.7 describes the three injection sites for IM injections.
Site | Additional Information | ||
Ventrogluteal | The site involves the gluteus medius and minimus muscle and is the safest injection site for adults and children. The site provides the greatest thickness of gluteal muscles, is free from penetrating nerves and blood vessels, and has a thin layer of fat. To locate the ventrogluteal site, place the patient in a supine or lateral position (on their side). The right hand is used for the left hip, and the left hand is used for the right hip. Place the heel or palm of your hand on the greater trochanter, with the thumb pointed toward the belly button. Extend your index finger to the anterior superior iliac spine and spread your middle finger pointing towards the iliac crest. Insert the needle into the V formed between your index and middle fingers. This is the preferred site for all oily and irritating solutions for patients of any age. Needle gauge is determined by the solution. An aqueous solution can be given with a 20 to 25 gauge needle. Viscous or oil-based solutions can be given with 18 to 21 gauge needles. The needle length is based on patient weight and body mass index. A thin adult may require a 16 mm to 25 mm (5/8 to 1 inch) needle, while an average adult may require a 25 mm (1 inch) needle, and a larger adult (over 70 kg) may require a 25 mm to 38 mm (1 to 1 1/2 inch) needle. Children and infants will require shorter needles. Refer to the agency policies regarding needle length for infants, children, and adolescents. For the ventrogluteal muscle of an average adult, give up to 3 ml of medication. | ||
Vastus lateralis
| The vastus lateralis is commonly used for immunizations in children from infants through to toddlers. The muscle is thick and well developed. This muscle is located on the anterior lateral aspect of the thigh and extends from one hand’s breadth above the knee to one hand’s breadth below the greater trochanter. The middle third of the muscle is used for injections. The width of the muscle used extends from the mid-line of the thigh to the mid-line of the outer thigh. To help relax the patient, ask the patient to lie flat with knees slightly bent, or have the patient in a sitting position. The length of the needle is based on the patient’s age, weight and body mass index. In general, the recommended needle length for an adult is 25 mm to 38 mm (1 to 1 1/2 inch). The gauge of the needle is determined by the type of medication administered. Aqueous solutions can be given with a 20 to 25 gauge needle; oily or viscous medication should be administered with 18 to 21 gauge needles. A smaller gauge needle (22 to 25 gauge) should be used with children. The length will be shorter for infants and children; see agency guidelines. The maximum amount of medication for a single injection is 3 ml. | ||
Deltoid muscle | The deltoid muscle has a triangular shape and is easy to locate and access, but is commonly underdeveloped in adults. Begin by having the patient relax the arm. The patient can be standing, sitting, or lying down. To locate the landmark for the deltoid muscle, expose the upper arm and find the acromion process by palpating the bony prominence. The injection site is in the middle of the deltoid muscle, about 2.5 to 5 cm (1 to 2 inches) below the acromion process. To locate this area, lay three fingers across the deltoid muscle and below the acromion process. The injection site is generally three finger widths below, in the middle of the muscle. Select needle length based on age, weight, and body mass. In general, for an adult male weighing 60 to 118 kg (130 to 260 lbs), a 25 mm (1 inch) needle is sufficient. For women under 60 kg (130 lbs), a 16 mm (5/8 inch) needle is sufficient, while for women between 60 and 90 kg (130 to 200 lbs), a 25 mm (1 inch) needle is required. A 38mm (1 1/2 inch) length needle may be required for women over 90 kg (200 lbs) for a deltoid IM injection. Refer to agency policy regarding specifications for infants, children, adolescents, and immunizations. The maximum amount of medication for a single injection is generally 1 ml. For immunizations, a smaller 22 to 25 gauge needle should be used. | ||
Data source: Berman & Snyder, 2016; Davidson & Rourke, 2014; Ogston-Tuck, 2014a; Perry et al., 2014 |
Consider the type of medication and the age, condition, and size of the patient when selecting an IM site. Rotate IM sites to avoid complications. Potential complications include lingering pain, tissue necrosis, abscesses, and injury to blood vessels, bones, or nerves. If administering a vaccination, always refer to the vaccination guidelines for site selection. Checklist 58 outlines the steps to perform an IM injection.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
Assessment | |||
1. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
2. Compare MAR to patient wristband and use two patient identifiers to confirm patient. | Using two identifiers improves medication safety by ensuring you have selected the correct patient. | ||
3. Assess the patient’s symptoms, knowledge of the medication to be received, history of allergies, drug allergies, and types of allergic reactions. | Assess patient data such as vital signs, laboratory values, and allergies before preparing and administering medications by injection. | ||
4. Assess for any factors that may contraindicate an IM injection. | Factors to look for include circulatory shock, surgery, or muscle atrophy. | ||
Preparation | |||
5. Verify practitioner’s order and MAR. | |||
6. Review medication information, such as purpose, action, side effects, normal dose, rate of administration, time of onset, peak and duration, and nursing implications. | Knowledge of the medication ensures the correct patient receives the correct dose of the correct medication at the correct time via the correct route for the correct reason using the correct documentation. | ||
7. Assemble supplies. | Assemble medication, non-sterile gloves, alcohol swabs, syringes, needles, and sharps container. | ||
8. Prepare medication from an ampule or a vial as per hospital policy. Always compare MAR to the practitioner’s original orders to ensure accuracy and completeness. | This prevents medication errors by providing an additional check. | ||
9. NEVER leave the medication unsupervised once prepared. | Medications left unattended may lead to medication errors. | ||
Procedure | |||
10. Perform hand hygiene. | Hand hygiene prevents the transmission of microorganisms. | ||
11. Close curtains or door. | This creates privacy for the patient. | ||
12. Verify patient using two unique identifiers and compare to MAR. | This step confirms the correct identity of the patient. | ||
13. Explain the procedure and the medication, and give the patient time to ask questions. | Knowing what is happening helps minimize patient anxiety. Let the patient know there may be mild burning at the injection site. | ||
14. Don non-sterile gloves and prepare the patient in the correct position. Ensure a sharps disposal container is close by for disposal of needle after administration. | This prepares the patient for injection. Ensuring the sharps container is close by allows for safe disposal of the needle. | ||
15. Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. Allow site to dry completely. | Allowing the site to dry prevents stinging during injection. | ||
16. Place a clean swab or dry gauze between your third and fourth fingers. | This allows for easy access to dry gauze after injection. | ||
17. Remove needle cap by pulling it straight off the needle. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. | This prevents needle from touching side of the cap and prevents contamination. | ||
18. With non-dominant hand, hold the skin around the injection site. | This secures the area for injection. | ||
19. With the dominant hand, inject the needle quickly into the muscle at a 90-degree angle, using a steady and smooth motion. | Insert the needle with a dart-like motion. | ||
20. After the needle pierces the skin, use the thumb and forefinger of the non-dominant hand to hold the syringe. | Movement of the needle once injected can cause additional discomfort for the patient. | ||
21. If required by agency policy, aspirate for blood. If no blood appears, inject the medication slowly and steadily. If blood appears, discard syringe and needle, and prepare the medication again. | Because the injection sites recommended for immunizations do not contain large blood vessels, aspiration is not necessary when immunizing. | ||
22. Once medication is completely injected, remove the needle using a smooth, steady motion. Remove the needle at the same angle at which it was inserted. | Using a smooth motion prevents any unnecessary pain to the patient.
| ||
23. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. | Covering prevents infection at the injection site. | ||
24. Place safety shield on needle and discard syringe in appropriate sharps container. | Placing sharps in appropriate puncture-proof and leak-proof receptacles prevents accidental needle-stick injuries. | ||
25. Discard supplies, remove gloves, and perform hand hygiene. | This step prevents the spread of microorganisms. | ||
26. Document procedure as per agency policy. | Document the medication, time, route, site, date of administration, and effect of the medication; any adverse effects; unexpected outcomes; and any interventions applied. | ||
27. Assess patient’s response to the medication after the appropriate time frame. | Assess for effectiveness of the medication (onset, peak, and duration). Assess injection site for pain, bruising, burning, or tingling. | ||
Data source: CDC, 2013, 2015; Perry et al., 2014 |
Checklist 59 outlines the steps to perform a Z-track IM injection.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
Assessment | |||
1. Perform hand hygiene. | Hand hygiene prevents the spread of microorganisms. | ||
2. Compare Mar to the patient’s wristband and use two patient identifiers to confirm patient. | Using two identifiers improves medication safety by ensuring you have selected the correct patient. | ||
3. Assess the patient’s symptoms, knowledge of the medication to be received, history of allergies, drug allergies, and types of allergic reactions. | Assess patient data such as vital signs, laboratory values, and allergies before preparing and administering medications by injection. | ||
4. Assess for any factors that may contraindicate an injection. | Factors to look for include circulatory shock, surgery, or muscle atrophy. | ||
Preparation | |||
5. Verify practitioner’s order and MAR. | |||
6. Review medication information such as purpose, action, side effects, normal dose, rate of administration, time of onset, peak and duration, and nursing implications. | Knowledge of the medication ensures the correct patient receives the correct dose of the correct medication at the correct time via the correct route for the correct reason using the correct documentation. | ||
7. Verify expiry date and check for particulates, discoloration, or loss of integrity (sterility). | Discoloured or outdated medication may be harmful. If a medication is discoloured or cloudy, always check manufacturer’s specification for the medication. | ||
8. Assemble supplies. | Assemble medication, non-sterile gloves, syringes, needles, and sharps container. | ||
9. Prepare medication from an ampule or a vial as per hospital policy. Always compare MAR to the practitioner’s original orders to ensure accuracy and completeness. | This prevents medication errors by providing an additional check. | ||
10. NEVER leave the medication unsupervised once prepared. | Unsupervised medication may lead to medication errors | ||
Procedure | |||
11. Perform hand hygiene. | Hand hygiene prevents transmission of microorganisms | ||
12. Close curtains or door. | This creates privacy for the patient. | ||
13. Verify patient using two unique identifiers and compare to MAR. | This confirms the correct identity of the patient. Follow policy for safe medication administration. | ||
14. Explain the procedure and the medication, and give the patient time to ask questions. | Knowing what is happening helps minimize patient anxiety. Let the patient know there may be mild burning at the injection site. | ||
15. Don non-sterile gloves, select the correct site, and prepare the patient in the correct position. Ensure a sharp disposal container is close by for disposal of needle after administration. | This prepares the patient for injection. Ensuring the sharps container is close by allows for safe disposal of the needle. | ||
16. Locate correct site using landmarks, and clean area with alcohol or antiseptic swab. Allow site to dry completely. | Allowing the site to dry prevents stinging during injection.
| ||
17. Place a clean swab or dry gauze between your third and fourth fingers. | This allows for easy access to dry gauze after injection. | ||
18. Remove needle cap by pulling it straight off the needle. Hold syringe between thumb and forefinger on dominant hand as if holding a dart. | This prevents needle from touching side of the cap and prevents contamination. | ||
19. Displace skin in a Z-track manner by pulling the skin down or to one side about 2 cm (1 in.) with your non-dominant hand. | The Z-track method creates a zigzag path to prevent medication from leaking into the subcutaneous tissue. This method may be used for all injections, or may be specified by the medication. | ||
20. With skin held to one side, quickly insert needle at a 90-degree angle. After needle pierces skin, continue pulling on skin with non-dominant hand, and at the same time grasp lower end of syringe barrel with fingers of non-dominant hand to stabilize it. Move dominant hand to end of plunger. If required by agency policy, aspirate for blood. If no blood appears, inject the medication slowly. | Insert the needle with a dart-like motion. A quick injection is less painful. Inject medication at 10 seconds/ml. Because the injection sites recommended for immunizations do not contain large blood vessels, aspiration is not necessary when immunizing. | ||
21. Once medication is given, leave the needle in place for 10 seconds. Avoid moving the syringe. | Leaving the needle in place allows the medication to be displaced. Movement of the needle can cause additional discomfort for the patient. | ||
22. Once medication is completely injected, remove the needle using a smooth, steady motion. Then release the skin. | Using a smooth motion prevents any unnecessary pain to the patient. | ||
23. Cover injection site with sterile gauze, using gentle pressure, and apply Band-Aid as required. Do not massage site. | Covering prevents infection at the injection site. | ||
24. Place safety shield or needle guard on needle and discard syringe in appropriate sharps container. | Placing sharps in appropriate puncture-proof and leak-proof receptacles prevents accidental needle-stick injuries. | ||
25. Discard supplies, remove gloves, and perform hand hygiene. | This step prevents the spread of microorganisms. | ||
26. Document procedure as per agency policy. | Document the medication, time, route, site, date of administration, and effect of the medication; any adverse effects; unexpected outcomes; and any interventions applied. | ||
27. Assess patient’s response to the medication after the appropriate time frame. | Assess for effectiveness of the medication (onset, peak, and duration). Assess injection site for pain, bruising, burning, or tingling. | ||
Data source: Centers for Disease Control, 2013, 2015; Perry et al., 2014 |
Critical Thinking Exercises
Intravenous (IV) is a method of administering concentrated medications (diluted or undiluted) directly into the vein using a syringe through a needleless port on an existing IV line or a saline lock. The direct IV route usually administers a small volume of fluid/medicine (max 20 ml) that is pushed manually into the patient. Medications given by IV are usually administered intermittently to treat emergent concerns. Medications administered by direct IV route are given very slowly over AT LEAST 1 minute (Perry et al., 2014). Administering a medication intravenously eliminates the process of drug absorption and breakdown by directly depositing it into the blood. This results in the immediate elevation of serum levels and high concentration in vital organs, such as the heart, brain, and kidneys. Both therapeutic and adverse effects can occur quickly with direct intravenous administration (Alberta Health Services, 2009).
In the past, IV medications have been called IV bolus or IV push medications. It is recommended that these terms NOT be used, as they can be mistakenly interpreted as meaning the drugs are to be pushed quickly, in less than a minute (ISMP, 2003). To administer IV medications safely and effectively, all health care agencies have policies in place and the Parenteral Drug Therapy Manual (PDTM) that identifies medications that may be given intravenously. (The PDTM may also be referred to as a parenteral drug monograph [Alberta Health Services, 2009].) Only specific medications may be administered via the direct IV route. There are many advantages and disadvantages to administering medications via the intravenous injection method — see Table 7.8.
Advantages | Disadvantages | ||
Intravenous medications can deliver an immediate, fast-acting therapeutic effect, which is important in emergent situations such as cardiac arrest or narcotic overdose. They are useful to manage pain and nausea by quickly achieving therapeutic levels, and they are more consistently and completely absorbed compared with medications given by other routes of injection. | Once an intravenous medication is delivered, it cannot be retrieved. When giving IV medications, there is very little opportunity to stop an injection if an adverse reaction or error occurs. IV medications, if given too quickly or incorrectly, can cause significant harm or death. | ||
Doses of short-acting medication can be titrated according to patient responses to drug therapy. Medication can be prepared quickly and given over a shorter period of time compared to the IV piggyback route. | Any toxic or adverse reaction will occur immediately and may be exacerbated by a rapidly injected medication. | ||
Minimal dilution is required for some medications, which is desirable for patient’s own fluid restrictions. | Extravasation of certain medications into surrounding tissues can cause sloughing, nerve damage, and scarring. | ||
There is minimal or no discomfort for the patient in comparison to SC and IM injections. | Not all medications can be given via the direct IV route. | ||
They provide an alternative to the oral route for drugs that may not be absorbed by the GI tract, and they are ideal for patients with GI dysfunction or malabsorption, and patients who are NPO (nothing by mouth) or unconscious. | There is a high risk for infusion reactions, mild to severe, because most IV medications peak rapidly (i.e., they have a quick onset of effect). A hypersensitivity reaction can occur immediately or be delayed, and requires supportive measures. | ||
IV direct route provides a more accurate dose of medication because none is left in the intravenous tubing. | Route for administering medications may damage surrounding tissues. There is an increased risk of phlebitis with highly concentrated medication, especially with small peripheral veins or a short venous access device. | ||
Data source: Albert Health Services, 2009; Lynn, 2011; Perry et al., 2014 |
Intravenous medications are always prepared using the SEVEN rights x 3 as per agency policy. Because of the high risk associated with direct intravenous medications, additional guidelines are required. A PDTM or drug monograph provides additional information, which includes the generic name, brand name, classification of the drug, and chart defining which parenteral route may be utilized. Some medications may only be given via a piggyback method or large-volume IV solutions; some medications may be given diluted over 1 or 2 minutes. In addition, information regarding indications, contraindications, dosage (age dependent), administration/dilution guidelines, adverse effects, clinical indications (e.g., specialized monitoring required, must be on an IV pump), compatibility, and incompatibility in relation to reconstitution and primary IV solution is specified (Alberta Health Services, 2009).
The Institute for Safe Medication Practices (ISMP) (2014) has created a list of high-alert medications that bear the heightened risk of significant harm when they are used in error. Special safeguards for these medications can be found in the PDTM. It is vital to understand which medications are considered high risk prior to administration. A link to the list of high-risk medications can be found under Suggested Online Resources at the end of this chapter. Review the steps shown in Table 7.9 to prepare a medication by direct IV route. The PDTM must be consulted every time an IV medication is given, as memory-based errors are common (World Health Organization, 2012).
Before giving an intravenous medication, always assess the IV needle insertion site for signs of infiltration or phlebitis. Start a new IV site if current site is red, swollen, or painful when flushing. Intravenous medications by direct IV route can be given three ways:
Checklist 60 reviews the steps to administer an IV medication through a saline lock. Review the preparation questions for intravenous medication in Table 7.9 prior to administering medication.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
1. Prepare one medication for one patient at the correct time as per agency policy. Review the physician’s order, PDTM, and MAR for the correct order and guidelines. Math calculations may be required to determine the correct dose to prepare the medication. | Always apply the SEVEN rights x 3 of medication administration. Review the agency policy if a medication is a stat, given for the first time, a loading dose, or a one-time dose. Some agencies require that high-alert medications be double-checked by a second health care provider. Always follow agency policies. For a list of high-alert medications, see Suggested Online Resources. After preparing the medication, always label the medication syringe with the patient name, date, time, medication, and concentration of the dose (e.g., morphine 2 mg/ml), dose, and your initials. Never leave the medication syringe unattended. | ||
2. Create privacy if possible. | This provides comfort to patient. | ||
3. Confirm patient ID using two patient identifiers (e.g., name and date of birth) AND compare the MAR printout with the patient’s wristband to confirm patient ID. | This ensures you have the correct patient and complies with agency standard for patient identification. | ||
4. Check allergy band for any allergies, and ask patient about type and severity of reaction. | This ensures allergy status is correct on the MAR and on patient allergy band. | ||
5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning). | Keeping patient informed of what is being administered helps decrease anxiety. | ||
6. Perform hand hygiene. | Hand hygiene prevents the transmission of microorganisms. | ||
7. Clean access port in a circular motion with an alcohol swab for 15 seconds. Allow to dry. | This technique prevents introduction of microorganisms by the syringe. | ||
8. Remove air from prefilled syringe. Release clamp on extension tubing and flush the saline lock with 3 to 5 ml of normal saline to ensure patency. Do not force if resistance is felt. Remove syringe. | If swelling, pain, or redness exists, remove IV cannula and restart new IV site. Tenderness is the first sign of phlebitis. | ||
9. Attach medication syringe (without needle) to access device. | Using a needleless system prevents needle-stick injuries. | ||
10. Using a timer with a second hand, inject medication at the correct rate according to agency policy. Use a push-pause method to inject the medication. | Using a timer ensures safe medication administration. Rapid injection of IV medications can be fatal. A slow rate allows medications to be administered correctly. | ||
11. Remove used medication syringe. Remove air from prefilled NS syringe and attach to the Max Plus device. Flush (3 to 5 ml) at the SAME rate as the medication bolus, according to guidelines found in the PDTM or per IV bolus medication policy. (See Rationale for Flushing with NS after Administering an IV Medication.)
| Always check hospital policy on the amount of flush and type of solution when using a saline lock for an IV bolus medication. Flushing the IV line at the same rate as medication delivery ensures that any medication remaining within the IV line is delivered at the correct rate, and avoids giving the patient an accidental bolus of the medication. Flushing the saline lock clears the medication from the device. Establish positive pressure as per manufacturer’s directions. If a patient has a central venous catheter, access and flush as per agency policy. | ||
12. Dispose of all syringes/filter needles into appropriate puncture-proof containers. | This prevents accidental needle-stick injuries. | ||
13. Remove gloves and perform hand hygiene. | This reduces transmission of microorganisms. | ||
14. Document as per agency protocol. | Document the time, reason, drug, dose, effect, and any adverse reactions. | ||
15. Observe for expected therapeutic effect and for adverse effects. | The patient needs to be evaluated and monitored, especially for high-alert medications. IV medications act rapidly. | ||
Data source: Canadian Institute for Health Information, 2009; Clayton et al., 2010; Perry et al., 2014 |
Flushing after IV medication administration with compatible IV solution is recommended as per the guidelines in Checklists 60, Checklist 61, and Checklist 62 to ensure that medication left in the extension tubing is administered at the appropriate rate. IV medication must be cleared by flushing at the same rate of administration to avoid the risks related to IV push medications. Because 1 ml of medication is left in the extension tubing, due care in flushing is required for the first ml that clears the extension tubing. The remaining saline flush serves to maintain patency of the line.
Here are some examples of clearing IV medication from extension tubing.
When flushing an IV line after administering an IV medication, the following applies:
Checklist 61 lists the steps to administering an IV medication through an existing IV line with compatible IV solution. Review the preparation questions for intravenous medication in Table 7.9 prior to the medication administration.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
1. Prepare one medication for one patient at the correct time as per agency policy. Review the physician’s order, PDTM, and MAR for the correct order and guidelines. Math calculations may be required to determine the correct dose to prepare the medication. | Always apply the SEVEN rights x 3 of medication administration. Review the agency policy if a medication is a stat, first-time, loading dose, or a one-time dose. Some agencies require that high-alert medications be double-checked by a second health care provider. Always follow agency policies. After preparing the medication, always label the medication syringe with the patient name, date, time, medication and dose concentration (e.g. morphine 2 mg/ml), dose, and your initials. Never leave the syringe unattended. | ||
2. Create privacy if possible. | This provides comfort to patient. | ||
3. Confirm patient ID using two patient identifiers (e.g., name and date of birth) AND compare the MAR printout with the patient’s wristband to confirm patient ID. | This ensures you have the correct patient and complies with agency standard for patient identification. | ||
4. Check allergy band for any allergies, and ask patient about type and severity of reaction. | This ensures allergy status is correct on the MAR and on patient allergy band. | ||
5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning). | Keeping patient informed of what is being administered helps decrease anxiety. | ||
6. Perform hand hygiene and apply non-sterile gloves. | Hand hygiene prevents the transmission of microorganisms. | ||
7. Select IV access port closest to the patient. | |||
8. Clean port in a circular motion with an alcohol swab for 15 seconds. Allow to dry. | This prevents introduction of microorganisms by the syringe. | ||
9. Attach syringe (without needle) to IV line using needleless system. If running primary IV solution is medication (e.g., heparin, morphine, pantaloc, insulin, or blood or blood products), do not flush. Start another saline lock on the opposite arm. | Using a needleless system prevents needle-stick injuries. Never administer a medication using a filter needle. | ||
10. If IV solution is on an IV pump, pause the device. Pinch IV tubing above the lowest access port or use blue slider clamp. | This prevents the IV medication from travelling up the IV line. | ||
11. Inject medication at the recommended rate according to agency policy. Use a timer to monitor time. Use a push-pause method to inject the medication. | This ensures safe medication administration at the correct rate. Rapid injection of IV medications can be fatal. | ||
12. Remove used medication syringe. Remove air from prefilled NS syringe and attach to the same IV port. Flush (3 to 5 ml) at the SAME rate as the medication bolus, according to guidelines found in the PDTM or per IV bolus medication policy. (See Rationale for Flushing with NS after Administering an IV Medication.)
| No needle should be present with a needleless system. | ||
13. Unpinch/unclamp the IV tubing and ensure the IV is infusing at the correct rate. Restart IV infusion device as required. | |||
14. Dispose of all syringes/filter needles into appropriate puncture-proof containers if required. | This prevents accidental needle-stick injuries. | ||
15. Remove gloves and perform hand hygiene. | This reduces transmission of microorganisms. | ||
16. Document as per agency protocol. | Document time, reason, drug, dose, therapeutic effect, and any adverse reactions. | ||
17. Evaluate the patient for therapeutic effect and adverse reactions according to appropriate time frame (onset and peak of medication). | Observations provide additional safety measures, especially for high-alert medications. IV medications act rapidly. | ||
Data source: Berman & Snyder, 2016; Canadian Institute for Health Information, 2009; Clayton et al., 2010; Perry et al., 2014; Workers Compensation Act, 2015 |
Checklist 62 reviews the steps to administer an IV medication through an existing IV line with incompatible IV solution. Review the preparation questions for intravenous medication in Table 7.9 prior to the medication administration.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
1. Prepare one medication for one patient at the correct time as per agency policy. Review the physician orders, PDTM, and MAR for the correct order and guidelines. Math calculations may be required to determine the correct dose to prepare the medication. | Always apply the SEVEN rights x 3 of medication administration. Review the agency policy if a medication is a stat, first-time, loading dose, or a one-time dose. Some agencies require that high-alert medications be double-checked by a second health care provider. Always follow agency policies. After preparing the medication, always label the medication syringe with the patient name, date, time, medication and dose concentration (e.g. morphine 2 mg/ml), dose, and your initials. Never leave the syringe unattended. | ||
2. Create privacy if possible. | This provides comfort to patient. | ||
3. Confirm patient ID using two patient identifiers (e.g., name and date of birth) AND compare the MAR printout with the patient’s wristband to confirm patient ID. | This ensures you have the correct patient and complies with agency standard for patient identification. | ||
4. Check allergy band for any allergies, and ask patient about type and severity of reaction. | This ensures allergy status is correct on the MAR and on patient allergy band. | ||
5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning). | Keeping patient informed of what is being administered helps decrease anxiety. | ||
6. Perform hand hygiene and apply non-sterile gloves. | Hand hygiene prevents the transmission of microorganisms. | ||
7. Clamp or pinch the IV line, and pause the infusion pump if required. | Always ensure the needle insertion site is patent, free from redness and swelling. Always check agency policy to ensure an IV solution or medication can be stopped temporarily. Some IV solutions may not be stopped. If unable to temporarily stop an IV solution or IV medication, start a new IV site. | ||
8. Clean the lowest port on the IV tubing with an alcohol swab in a circular motion for 15 seconds. Allow to dry. Clamp IV tubing above the lowest port on the IV tubing. | This prevents the transmission of microorganisms. | ||
9. Flush the IV line with 10 ml of normal saline or as per agency policy. | This step clears the IV line to prevent any mixing of incompatible medications. If running primary IV solution is medication (e.g., heparin, morphine, pantaloc, or insulin) or blood or blood products, do not flush. Start another saline lock on the opposite arm. | ||
10. Inject medication at the recommended rate according to agency policy. Use timer with second hand to time injection. Use a push-pause method to inject the medication. | Medications can be given safely when guidelines are followed. This ensures the medication is delivered at proper intervals according to agency policy. | ||
11. Remove used medication syringe. Remove air from prefilled NS syringe and attach to the same IV port. Flush (3 to 5 ml) at the SAME rate as the medication bolus, according to guidelines found in the PDTM or per IV bolus medication policy. (See Rationale for Flushing with NS after Administering an IV Medication.) | Flushing at the same rate prevents patient from accidentally receiving a bolus of the medication. Flushing also ensures the line is patent and clears the IV line of all incompatible medications. | ||
12. Unclamp/unpinch IV line and restart IV infusion device as required. Recheck infusion rate if IV solution is running by gravity. | Rechecking infusion rate prevents accidental fluid overload and keeps patient safe. | ||
13. Dispose of all syringes/filter needles into appropriate puncture-proof containers. | This prevents accidental needle-stick injuries. | ||
14. Remove gloves and perform hand hygiene. | This reduces the transmission of microorganisms. | ||
15. Document as per agency protocol. | Document time, reason, drug, dose, effect, and any adverse reactions. | ||
16. Evaluate the patient’s response to the medication in the appropriate time frame. | Observe patient for expected therapeutic effects and adverse reactions. | ||
Data source: Berman & Snyder, 2016; Canadian Institute for Health Information, 2009; Clayton et al., 2010; Perry et al., 2014 |
Critical Thinking Exercises
Intravenous intermittent infusion is an infusion of a volume of fluid/medication over a set period of time at prescribed intervals and then stopped until the next dose is required. An intermittent IV medication may be called a piggyback medication, a secondary medication, or a mini bag medication (see Figure 7.16). Intravenous medications may be given in small volumes of sterile IV solution (25 to 250 ml) and infused over a desired amount of time (given for 30 minutes every 4 hours) or as a single dose. Many medications must be given slowly to prevent harm to the patient, and this method of administration reduces the risk of rapid infusion. A piggyback medication is given through an established IV line that is kept patent by a continuous IV solution or by flushing a short venous access device (saline lock). Always check the Parenteral Drug Therapy Manual PDTM to ensure the correct guidelines are followed for each specific medication given in IV solution. The PDTM provides guidelines on how to mix the IV medication, the amount and type of solution, and the rate of infusion (Perry et al., 2014).
An intermittent medication may be administered by gravity or on an electronic infusion device (EID), also known as an infusion (IV) pump. Many piggyback IV medications must be on an IV pump, which requires programming and specialized training to prevent medication errors. The IV infusion pumps provide hard- and soft-dose limits and safety practice guidelines to aid in safe medication administration (Lynn, 2011). IV medications may also be given by gravity infusion, in which case the health care provider must calculate the infusion rate for drops per minute. The best practice for piggyback infusions is to use an IV infusion pump.
At times, a volume-controlled (intermittent infusion) set may be used to deliver medication for children, older adults, or critically ill patients where fluid volume is a concern. A volume-controlled intermittent set is a small device attached below the primary infusion to regulate the mini bag. The medication is added to a small amount of IV solution and administered through an IV line (Lynn, 2011).
Intravenous medications are always prepared using the seven rights x 3 as per agency policy. Because of the many high-risk events associated with intravenous medications, additional guidelines are required. A PDTM or monograph provides this additional information, which includes the generic name, brand name, classification of the drug, and a chart defining which parenteral route may be utilized. Some medications may only be given via a piggyback method or large-volume IV solutions, and some medications may be given diluted over 1 to 2 minutes. In addition, information on indications, contraindications, dosage (age dependent), administration/dilution guidelines, adverse effects, clinical indications (e.g., specialized monitoring required, must be on an IV pump), and compatibility and incompatibility in relation to reconstitution and primary IV solution are specified (Alberta Health Services, 2009).
The Institute for Safe Medication Practices (2014) has created a list of high-alert medications that bear the heightened risk of significant harm when they are used in error. Specific safeguards for these medications can be found in the PDTM. It is vital to understand which medications are considered high risk prior to administration. A link to the list of high-alert medications can be found under Suggested Online Resources at the end of this chapter. In addition to the seven rights x 3 for medication preparation, Table 7.10 summarizes what to review in the PDTM when preparing and administering an intravenous medication. The acronym RED CARS can be used as a reminder.
Mnemonic | Additional Information | ||
R | Rate: What is the rate of injection? | ||
E | Equipment: Equipment may include a syringe, filter needle (vial), or non-filter needle (ampule), label for the syringe, alcohol swab, solution to prepare the medications, PDTM, MAR, non-sterile gloves, normal saline flushes, and a watch with a second hand. | ||
D | Dilution: How much solution is required to dilute the medication, and what type of solution (normal saline or dextrose)? Some intravenous medications must be administered in a piggyback or mini bag, and some may be given diluted directly into the vein through an existing IV line. | ||
C | Compatibility: Is the medication compatible with the primary IV solution and additives? NEVER inject intravenous medications into blood or blood products, or IV continuous infusions such as heparin IV or insulin IV. | ||
A | Allergies: What are the patient’s allergies and types of reactions? | ||
R | Reconstitution: If the medication requires reconstitution, follow directions for adding the correct amount of dilution and type of dilution. Use the information to accurately achieve the correct concentration of the medication. | ||
S | Stability: How long is the medication stable at room temperature or when reconstituted? | ||
Data source: BCIT, 2015 |
Using sterile technique, prepare the intravenous medication as per agency policy, using the PDTM and the seven rights x 3. Many piggyback medications come prepared from the pharmacy and still require a complete check (SEVEN rights x 3) prior to administration. Checklist 63 lists the steps to administering an intermittent IV medication by gravity or an IV infusion pump.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
1. Prepare one medication for one patient at the correct time as per agency policy. Always check the physician orders, PDTM, and MAR. Mathematical calculations may be required to determine the correct dose to prepare. | Always apply the SEVEN rights of medication administration. Review the agency policy and the PDTM. If a medication is a stat, first-time, loading, or one-time dose, be extra diligent in reviewing the PDTM. Memory slips are a common source of error with medication administration. Complete all assessments (vital signs) and check laboratory values that may influence the medication administration. If piggyback (secondary) medication is made up by the health care provider, ensure the medication label on the mini bag includes the patient name, date, time, medication added, dose and concentration, expiry time, and your initials. Some health agencies require a second independent check with high-alert medications. Always follow agency policy. | ||
2. Perform hand hygiene and bring medication and MAR to bedside. Create privacy if possible. | Additional equipment required includes secondary tubing, a metal or plastic extension hanger, an alcohol swab, and a timer with a second hand. Creating privacy provides comfort to patient. | ||
3. Compare the MAR with the patient’s wristband, and use two patient identifiers (name and birth date), according to agency policy, to confirm patient ID. | This ensures you have the correct patient and complies with agency standard for patient identification. | ||
4. Ask about allergies. | This ensures allergy status is correct on the MAR and patient’s allergy band. | ||
5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning). | Keeping patient informed of what is being administered helps decrease anxiety. | ||
6. Perform hand hygiene. | Hand hygiene prevents the transmission of microorganisms. | ||
7. Assess IV site. Select upper port on the IV tubing. | IV medications may require assessment of vital signs and lab values prior to administration. | ||
8. Complete necessary assessments as required. Assess IV site and flush for patency. | Ensure IV site is free from redness, swelling, and pain prior to administering the medication. | ||
9. Prime secondary tubing. | Remove secondary tubing from packaging and close the clamp. Hang the medication IV bag on the IV pole and remove the sterile blue protective cap. Slowly open the clamp and prime the tubing. Clean the upper injection port on the primary IV tubing with an alcohol swab for 15 seconds using a circular motion. Allow to dry. Remove the cap on the distal end of the secondary tubing and carefully insert the upper injection port. Label the secondary tubing with date and time. | ||
10. Lower the primary IV solution bag using the extension hook. | Ensure piggyback mini bag is hung above the primary IV solution bag. Position of the IV solutions influences the flow of the IV fluid into the patient. The setup is the same if the medication is given by gravity or through an IV infusion pump. Always follow manufacturer’s directions for infusion pumps. | ||
11. Ensure clamp on secondary tubing is open. | This prevents the patient from missing a dose of medication. | ||
12a. If using gravity infusion, use the roller clamp on the primary set to regulate the rate. The rate will need to be calculated for gtts/mins. 12b. If using an IV infusion pump, set the rate according to the PDTM. Most infusion pumps automatically restart the primary infusion at the previously established rate. | If the medication is administered via gravity, remember to return to the patient and readjust the rate for the primary IV infusion. The primary IV solution will resume infusing at the rate of the secondary infusion, which could lead to rapid infusion of the primary solution. If medication is being given for the first time, stay with the patient for the first 5 minutes to monitor for any potential adverse effects. Encourage patient to notify the health care provider if IV site becomes red, painful, or swollen, or if patient notices any adverse effects from the medication. | ||
13. Leave IV piggyback mini bag and tubing in place for future drug administration. Check agency policy to verify if this practice is acceptable. | Repeated changes in IV tubing increase risk for infection transmission. Secondary IV tubing should be changed as per agency policy. | ||
14. Perform hand hygiene. | Hand hygiene reduces the transmission of microorganisms. | ||
15. Document administration of the IV piggyback on MAR, the I/O sheet, and as per agency policy. | Document time, therapeutic effect, and any adverse reactions. Prompt documentation avoids the possibility of accidentally repeating the administration of the drug. If the drug was omitted or refused, record this appropriately and notify the primary health care provider. | ||
Data source: Berman & Snyder, 2016; Lynn, 2011; Perry et al., 2014; WHO, 2012 |
Checklist 64 lists the steps to administer an intermittent IV medication using an existing secondary line, by gravity or an IV infusion pump.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety Considerations:
| |||
Steps | Additional Information | ||
1. Prepare one medication for one patient at the correct time as per agency policy. Always check the physician’s order, PDTM, and MAR. Mathematical calculations may be required to determine the correct dose to prepare. | Always apply the SEVEN rights of medication administration. Review the agency policy and the PDTM. If a medication is a stat, first-time, loading, or one-time dose, be extra diligent in reviewing the PDTM. Memory slips are a common source of error with medication administration. Complete all assessments and laboratory values that may influence the medication administration. If piggyback (secondary) medication is made up by the health care provider, ensure the medication label on the mini bag includes the patient name, date, time, medication added, dose and concentration, expiry time, and your initials. Some health agencies require a second independent check with high-alert medications. Always follow agency policy. | ||
2. Bring medication and MAR to bedside. Create privacy if possible. | Additional equipment required includes secondary tubing, a metal or plastic extension hanger, an alcohol swab, and a timer with a second hand. Creating privacy provides comfort to patient. | ||
3. Compare the MAR printout with the patient’s wristband, and use two patient identifiers (name and birth date), according to agency policy, to confirm patient ID. | This ensures you have the correct patient and complies with agency standard for patient identification. | ||
4. Ask about allergies. | This ensures allergy status is correct on the MAR and the patient’s allergy band. | ||
5. Discuss purpose, action, and possible side effects of the medication. Provide patient an opportunity to ask questions. Encourage patient to report discomfort at the IV site (pain, swelling, or burning). | Keeping patient informed of what is being administered helps decrease anxiety. | ||
6. Perform hand hygiene. | Hand hygiene prevents the transmission of microorganisms. | ||
7. Complete necessary assessments as required. Assess IV site for patency. | IV medications may require assessment of vital signs and lab values prior to administration. IV site must be patent prior to use. | ||
8. Prime the secondary IV line by “back filling” using the empty IV mini bag attached to the secondary IV line. | Check expiration date on secondary IV tubing. Open the clamp on the secondary IV line and lower the mini bag below the primary IV line. This will cause IV solution from the primary IV bag to enter the old mini bag and clear out the secondary IV line. Allow approximately 25 ml of IV solution to enter the used mini bag. Once the secondary IV line is cleared, close the clamp on the secondary IV line, and ensure the drip chamber is 1/2 full. Remove the old mini bag from the secondary IV tubing and place on the bedside table. Carefully remove sterile blue cover on new medication bag, and insert the spike of the secondary IV tubing into the new IV bag, being careful to avoid accidental contamination. Open clamp on the secondary IV tubing. | ||
9. Ensure piggyback mini bag is hung above the primary IV solution bag. | Position of the IV solutions influences the flow of the IV fluid into the patient. The setup is the same if the medication is given by gravity or through an IV infusion pump. Always follow manufacturer’s directions for infusion pumps. | ||
10. Ensure clamp on secondary tubing is open. | This prevents the patient from missing a dose of medication. | ||
11a. If using gravity infusion, use the roller clamp on the primary set to regulate the rate. The rate will be calculated for gtts/mins. 11b. If using an IV infusion pump, set the rate according to the PDTM. Most infusion pumps automatically restart the primary infusion at the previously established rate. | If administering IV medication by gravity, remember to return to the patient and readjust the rate for the primary IV infusion. The primary IV solution will resume infusing at the rate of the secondary infusion, which could lead to rapid infusion of the primary solution. If medication is being given for the first time, stay with the patient for the first 5 minutes to monitor for any potential adverse effects. Encourage patient to notify the health care provider if IV site becomes red, painful, or swollen, or if patient notices any adverse effects from the medication. | ||
12. Leave IV mini bag and tubing in place for future drug administration. Check agency policy to verify if this practice is acceptable. | Repeated changes to IV tubing increase risk for infection transmission. Secondary IV tubing should be changed as per agency policy. | ||
13. Perform hand hygiene. | Hand hygiene reduces the transmission of microorganisms. | ||
14. Document administration of the IV piggyback on MAR, and as per agency policy. | Document time, therapeutic effect, and any adverse reactions Prompt documentation avoids the possibility of accidentally repeating the administration of the drug. If the drug was omitted or refused, record this appropriately and notify the primary health care provider. | ||
Data source: Clayton et al., 2010; Lynn, 2011; Perry et al., 2014; WHO, 2012 |
A continuous intravenous infusion is the infusion of a parenteral drug over several hours (continuous drip) to days. It involves adding medication to sterile IV solution (100 to 1,000 ml bag), and then hanging the IV solution as a primary infusion. A continuous drip must be ordered by the physician and listed in the PDTM as a medication to be given by IV continuous infusion. Most IV continuous infusions are given for a short duration. Examples of continuous IV infusion medications include heparin, insulin R, and pantaprazole. Continuous intravenous infusions may come pre-made from the pharmacy, and are labelled with the patient name; IV solution; volume, amount, and concentration of medication; initials of the RN; and date and time prepared (Alberta Health Services, 2009). Always refer to the PDTM for guidelines on how to administer, regulate, and titrate continuous infusions.
An electronic infusion device (EID) must be used to infuse continuous IV medications. Assessments and lab values must be monitored following the PDTM guidelines. A health care provider must assess the continuous medication for the dose, rate, and patency of the IV site, and assess the patient for therapeutic and adverse reactions to the medication. The Institute for Safe Medication Practices (ISMP) (2013) recommends that all high-alert medications be independently double-checked to detect potential harmful errors before they reach the patient. Independent double checks have been shown to detect up to 95% of errors (ISMP Canada, 2013).
Critical Thinking Exercises
Safe medication administration requires special attention to transition points where medication errors are more likely to occur. For example, many errors occur in the ordering and preparing phase. Many parenteral medications are considered high-alert medications because of the potential significant harm when used in error. Therefore, these medications require special safeguards to reduce the risk of error. ISMP (2014) lists IV medications classified as high alert. All parenteral routes of insulin (SC/IV) are considered high alert (ISMP, 2014). Specific safeguards may include:
In addition, complications may occur if medication is injected incorrectly, if incorrect equipment (needle or syringe) is used to prepare the medication, or if an error occurs in preparing (calculation, selection of the med), administration, or post-assessment of the patient receiving the medication. Additional complications may include nerve or tissue damage, medication being absorbed too fast or too slow, wrong location for the medication, pain, bleeding, or a sterile abscess (Perry et al., 2014).
Despite safe medication administration practices, an adverse reaction may happen to a patient for a variety of complex reasons and contributing factors (College of Nurses of Ontario, 2015). An adverse reaction, also known as an adverse event, is an undesirable effect of any health product such as prescription and non-prescription pharmaceuticals, vaccines, serums, and blood-derived products; cells, tissues, and organs; disinfectants; and radiopharmaceuticals. An adverse reaction may occur under normal use and conditions of the product. Reactions may be evident within minutes or years after exposure to the product and may range from minor reactions, like a skin rash, to serious and life-threatening events such as a heart attack or liver damage (Health Canada, 2012). For example, some IV bolus medications may cause a sudden drop in blood pressure or heart rate, or hives may result.
Table 7.11 lists five steps to manage an adverse reaction.
Step | Additional Information | ||
1. | Immediately stop the injection (or infusion) of the medication. Keep syringe of medication for further investigation of the reaction. | ||
2. | Assess and monitor vital signs. Alert other members of the health care team and ask for assistance as required. Provide reassurance to the patient about the event. | ||
3. | Notify responsible health care provider. | ||
4. | Perform interventions (CPR, O2 support) as required. Ensure patient has a patent IV site for any required medications to manage the adverse reaction. | ||
5. | Document and report the event through PSLS or agency-specified reporting system. | ||
Data source: Alberta Health Services, 2009; Clayton et al., 2010; College of Nurses of Ontario, 2015; Health Canada, 2012 |
Complications may result from direct, continuous, or secondary IV medications. The complications are not specific to one medication. It is important for the health care provider to know which adverse event may occur with each individual medication. For example, the administration of an IV opioid (narcotic) medication could result in respiratory depression. Table 7.12 provides a list of possible complications and related interventions.
Complications | Related Interventions | ||
Speed shock: A systemic reaction caused by the rapid injection of a medication into the circulation, resulting in toxic levels of medication in the plasma. Symptoms can include cardiac arrest, flushed face, headache, irregular pulse, shock, syncope, and tightness in the chest. | Use a peripheral IV site, if possible, to allow for maximum hemodilution before the medication reaches the heart/brain. Stay with the patient and observe for symptoms or changes in vital signs and level of consciousness during and after administration. Stop the injection immediately if the patient develops signs or symptoms of circulatory (drop in BP), respiratory (dyspnea), or neurological (decrease in LOC) deterioration during administration. | ||
IV medication is incompatible with IV fluids: Results in chemical or physical changes in their composition. Precipitates may form, colour may change (e.g., IV fluid becomes cloudy in the IV tubing), or the change may not be visible. Therapeutic effect of the medication may be reduced, obliterated, or potentiated. Toxic substances may be formed. | Always follow the guidelines in the PDTM. Do not mix medications in one syringe and only give one medication at a time. Never add medications to blood, blood products, or total parenteral nutrition. To avoid mixing of medications, ensure IV tubing and injection ports are flushed adequately between medication administrations. Stop the IV medication and flush with normal saline. If unable to give an IV medication due to incompatibles, start a new IV site or a new IV system (prime a new primary and secondary line) to administer the medication. Document changes and notify physician. | ||
IV site shows signs of phlebitis or irritation: Injection of medication into a vein may cause inflammation or roughening of the endothelial lining, which can result in thrombus formation. Medication may also be inadvertently injected into surrounding tissue, resulting in tenderness, pain, tissue necrosis, or nerve damage. Septic thrombophlebitis can result from poor aseptic technique. | Monitor for signs and symptoms, such as redness, swelling, pain, blanching, and streaking. If these signs are present, stop infusion immediately. Discontinue access device and restart in another site. If required, provide extravasation care as per agency policy. | ||
Data source: Alberta Health Services, 2009; Lynn, 2011 |
Medication errors are the leading cause of preventable errors in Canada (ISMP Canada, 2014). A medication incident is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labelling / packaging / nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.” (ISMP Canada, 2014, p.8)
Most of the critical incidents reported to the ISMP occurred during administration of a medication, with the wrong quantity of medication. The top five medications were hydromorphone, desmopressin, epinephrine, heparin, and morphine. Opioids continue to be the top medication classes associated with harmful incidents reported. Most of the opioid-related deaths involved overdoses, overlapping drug toxicities, administration of opioids to people who should not have received them, and use of hydromorphone (ISMP Canada, 2014).
Overall, the top three contributing factors were communication, independent check processes, and insufficient knowledge (ISMP Canada, 2014). Table 7.13 lists areas for improvement to prevent IV medication errors.
Area | Additional Information |
Monitoring of patient after medication administration | Be diligent in post-assessments of all IV medications. However, be particularly aware of high-alert medications, such as insulin, opioids, and anticoagulants. Many incident reports state that timely observation by a health care provider or family member prevents a bad outcome. Many overdoses can be reversed if caught in a timely manner. |
IV infusion pump errors | Errors can include:
To decrease patient harm, hospitals need additional funding to purchase more IV pumps. |
Health care technology | Computer-prescribed order entry (CPOE), automated dispensing cabinets (ADC), and other tools seek to improve patient safety and decrease errors. Protocols and force functioning need to be developed to minimize potential errors and to identify potential gaps in the system process. |
Reporting, analysis, and knowledge translation | The collection and analysis of incident reports is the backbone to further improvements. Without a robust system, there cannot be the identification of contributing factors to medication incidents. Always report near misses, adverse reactions, and medication errors to ensure investigation and improvement is initiated. In addition, shared learning and strategies are vital for safer health care. |
Data source: Clayton et al., 2010; ISMP Canada, 2014 |
Critical Thinking Exercises
Parenteral medication administration is an effective method of delivering medication to patients, and can be safely accomplished by utilizing the appropriate guidelines and policies in place to keep patients safe from harm. IV medications have a higher risk of harm than non-parenteral medication. The ever-increasing complexity of the health care environment increases the risk of a medication error with parenteral medications. The key takeaways below provide advice for preventing errors with parenteral medications.
Key Takeaways
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The use of intravenous (IV) therapy is common in the health care setting. IV therapy is a treatment that infuses fluids, nutrients, blood, blood products, or medication directly into a vein. It is a fast, efficient way to infuse fluids and medications into the body.
This chapter will review how to care for a patient with peripheral intravenous therapy and central venous catheters. It will cover how to prepare IV infusions, and how to assess, maintain, and prevent complications related to intravenous therapy.
Learning Objectives
Intravenous therapy is treatment that infuses intravenous solutions, medications, blood, or blood products directly into a vein (Perry, Potter, & Ostendorf, 2014). Intravenous therapy is an effective and fast-acting way to administer fluid or medication treatment in an emergency situation, and for patients who are unable to take medications orally. Approximately 80% of all patients in the hospital setting will receive intravenous therapy.
The most common reasons for IV therapy (Waitt, Waitt, & Pirmohamed, 2004) include:
The following are general guidelines for peripheral IV therapy:
Safe and reliable venous access for infusions is a critical component of patient care in the acute and community health setting. There are a variety of options available, and a venous access device must be selected based on the duration of IV therapy, type of medication or solution to be infused, and the needs of the patient. In practice, it is important to understand the options of appropriate devices available. This section will describe two types of venous access: peripheral IV access and central venous catheters.
A peripheral IV is a common, preferred method for short-term IV therapy in the hospital setting. A peripheral IV (PIV) (see Figure 8.1) is a short intravenous catheter inserted by percutaneous venipuncture into a peripheral vein, held in place with a sterile transparent dressing to keep the site sterile and prevent accidental dislodgement (CDC, 2011). Upper extremities (hands and arms) are the preferred sites for insertion by a specially trained health care provider. If a lower extremity is used, remove the peripheral IV and re-site in the upper extremities as soon as possible (CDC, 2011; McCallum & Higgins, 2012). The hub of a short intravenous catheter is usually attached to IV extension tubing with a positive pressure cap (Fraser Health Authority, 2014).
PIVs are used for infusions under six days and for solutions that are iso-osmotic or near iso-osmotic (CDC, 2011). They are easy to monitor and can be inserted at the bedside. CDC (2011) recommends that PIVs be replaced every 72 to 96 hours to prevent infection and phlebitis in adults. Most agencies require training to initiate IV therapy, but the care and preparation of equipment, and the maintenance of an IV system can be completed each shift by the trained health care provider. For more information on how to initiate IV therapy, see the resources at the end of the chapter.
PIVs are prone to phlebitis and infection, and should be removed (CDC, 2011) as follows:
Several potential complications may arise from peripheral intravenous therapy. It is the responsibility of the health care provider to monitor for signs and symptoms of complications and intervene appropriately. Complications can be categorized as local or systemic. Most complications are avoidable if simple hand hygiene and safe principles are adhered to for each patient at every point of contact (Fraser Health Authority, 2014; McCallum & Higgins, 2012). Table 8.1 lists the potential local and complications and treatment.
Complication | Signs, Symptoms, and Treatment | ||
Phlebitis | Phlebitis is the inflammation of the vein’s inner lining, the tunica intima. Clinical indications are localized redness, pain, heat, and swelling, which can track up the vein leading to a palpable venous cord. Mechanical causes: Inflammation of the vein’s inner lining can be caused by the cannula rubbing and irritating the vein. It is recommended to use the smallest gauge possible to deliver the medication or required fluids. Chemical causes: Inflammation of the vein’s inner lining can be caused by medications with a high alkaline, acidic, or hypertonic solutions. To avoid chemical phlebitis, follow the Parenteral Drug Therapy Manual (PDTM) guidelines for administering IV medications for the appropriate amount of solution and rate of infusion. Treatment: Immediately remove cannula. May elevate arm or apply a warm compress. Document findings in chart. Initiate a new peripheral IV if necessary. | ||
Infiltration | Infiltration occurs when a non-vesicant solution (IV solution) is inadvertently administered into surrounding tissue. Signs and symptoms include pain, swelling, redness, skin surrounding insertion site is cool to touch, change in quality or flow of IV, tight skin around IV site, IV fluid leaking from IV site, and frequent alarms on the IV pump. Treatment: Stop infusion and remove cannula. Follow agency policy related to infiltration. Always secure peripheral catheter with tape or IV stabilization device to avoid accidental dislodgement. Avoid areas of flexion and always assess IV site prior to giving IV fluids or IV medications. | ||
Extravasation | Extravasation occurs when vesicant solution (medication) is administered and inadvertently leaks into surrounding tissue, causing damage to surrounding tissue. Characterized by the same signs and symptoms as infiltration but also includes burning, stinging, redness, blistering, or necrosis of the tissue. Treatment: Stop infusion and remove cannula. Follow agency policy for extravasation for specific medications. For example, toxic medications have a specific treatment plan. | ||
Hemorrhage | Hemorrhage is defined as bleeding from the puncture site. Treatment: Apply gauze to the site until the bleeding stops, then apply a sterile transparent dressing. | ||
Local infection at IV site | Local infection is indicated by purulent drainage from site, usually two to three days after an IV site is started. Treatment: Remove cannula and clean site using sterile technique. Monitor for signs and symptoms of systemic infection. | ||
Data source: Fraser Health Authority, 2014; McCallum & Higgins, 2012 |
Systemic complications can occur apart from chemical or mechanical complications. To review the systemic complications of IV therapy, see Table 8.2.
Safety considerations:
| |||
Complication | Signs, Symptoms and Treatment | ||
Pulmonary edema | Pulmonary edema, also known as fluid overload or circulatory overload, is a condition caused by excess fluid accumulation in the lungs, due to excessive fluid in the circulatory system. It is characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness, dyspnea, and coughing up pinky frothy sputum. Pulmonary edema requires prompt medical attention and treatment. If pulmonary edema is suspected, raise the head of the bed, apply oxygen, take vital signs, complete a cardiovascular assessment, and notify the physician. | ||
Air embolism | Air embolism refers to the presence of air in the vascular system and occurs when air is introduced into the venous system and travels to the right ventricle and/or pulmonary circulation. An air embolism is reported to occur more frequently during catheter removal than during insertion, and the administration of up to 10 ml of air has been proven to have serious and fatal effects. Small air bubbles are tolerated by most patients. Signs and symptoms of an air embolism include sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and jugular venous distension. Treatment: Occlude source of air entry. Place patient in a Trendelenburg position on the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician promptly. To avoid air embolisms, ensure drip chamber is one-third to one-half filled, ensure all IV connections are tight, ensure clamps are used when IV system is not in use, and remove all air from IV tubing by priming prior to attaching to patient. | ||
Catheter embolism | A catheter embolism occurs when a small part of the cannula breaks off and flows into the vascular system. When removing a peripheral IV cannula, inspect tip to ensure end is intact. | ||
Catheter-related bloodstream infection | Catheter-related bloodstream infection (CR-BSI) is caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis. A CR-BSI is a nosocomial preventable infection and an adverse event. CR-BSI is confirmed in a patient with a vascular device (or a patient who had such a device in the last 48 hours before the infection) and no apparent source for the infection other than the vascular access device with one positive blood culture. Treatment: IV antibiotic therapy To avoid CR-BSI, perform hand hygiene prior to care and maintenance of an IV system, and use strict aseptic technique for care and maintenance of all IV therapy procedures. | ||
Data source: Fraser Health Authority, 2014; Fulcher & Frazier, 2007; McCallum & Higgins, 2012; Perry et al., 2014 |
A central venous catheter (CVC) (see Figure 8.2), also known as a central line or central venous access device, is an intravenous catheter that is inserted into a large vein in the central circulation system, where the tip of the catheter terminates in the superior vena cava (SVC) that leads to an area just above the right atrium. CVCs have become common in health care settings for patients who require IV medication administration and other IV treatment requirements. CVCs can remain in place for more than one year. Some CVC devices may be inserted at the bedside, while other central lines are inserted surgically. Central lines are inserted by a physician or specially trained health care provider, and the use of ultrasound guided placement is recommended to reduce time of insertion and complications (Safer Healthcare Now, 2012).
A CVC has many advantages over a peripheral IV line, including the ability to deliver fluids or medications that would be overly irritating to peripheral veins, and the ability to access multiple lumens to deliver multiple medications at the same time (Fraser Health Authority, 2014). Central venous catheters can be inserted percutaneously or surgically through the jugular, subclavian, or femoral veins, or via the chest or upper arm peripheral veins (Perry et al., 2014). Femoral veins are not recommended, as the rate of infection is increased in adults (CDC, 2011; Safer Healthcare Now, 2012). To have a CVC inserted or removed, an order by a physician or nurse practitioner must be obtained. Site selection for a CVC may be based on numerous factors, such as the condition of the patient, patient’s age, and type and duration of IV therapy.
The majority of patients in an ICU will have a CVC to receive fluids and medications. A chest X-ray is given to determine correct placement before inserting, or to confirm a suspected dislodgement (Fraser Health Authority, 2014). An IV pump must be used with all CVCs to prevent complications.
CVCs are typically inserted for patients requiring more than six days of intravenous therapy or who:
A central line is made up of lumens. A lumen is a small hollow channel within the CVC tube. A CVC may have single, double, triple, or quadruple lumens (Perry et al., 2014). Depending on the type of CVC, it may be internally or externally inserted, and may have an open-ended or valved tip. Open-ended devices are those in which the catheter tip is open like a “straw.” These have a higher risk for complications, such as hemorrhage, air embolism, and occlusion from fibrin or clots. Valved devices are those in which the tip is configured with a three-way pressure-activated valve (Perry et al., 2014). It is important to know what type of central line is being used, as this will impact how to care for and manage the equipment for specific procedures. Table 8.3 lists various types of central lines.
Safety considerations:
| |||
Type | Location and Additional Information | ||
Percutaneous central venous catheter (CVC) | Tip location: The tip of the catheter is located in the SVC. The entry site is the exit site. Can be inserted at the bedside by specially trained physician or nurse. The percutaneous CVC is inserted directly through the skin. The internal or external jugular, subclavian, or femoral vein is used. Most commonly used in critically ill patients. Can be used for days to weeks, and the patient must remain in the hospital. Usually held in place with sutures or a manufactured securement device.
| ||
Peripherally inserted central catheter (PICC) | Tip location: The tip is located in the SVC. A PICC (see Figure 8.3) may be inserted at the bedside, in a home or radiology setting. The line is inserted through the antecubital fossa or upper arm (basilic or cephalic vein) and is threaded the full length until the tip reaches the SVC. Can provide venous access for up to one year. The patient may go home with a PICC. PICCs can easily occlude and may not be used with dilantin IV. It is held in place with sutures or a manufactured securement device. | ||
Subcutaneous or tunnelled central venous catheter | A tunnelled CVC, also known as a Hickman, Broviac, or Groshong, is a long-term CVC with a proximal end tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site. Insertion is a surgical procedure, in which the catheter is tunnelled subcutaneously under the skin in the chest area before it enters the SVC. A tunnelled catheter may remain inserted for months to years. These CVCs have a low infection rate due to a Dacron cuff, an antimicrobial cuff surrounding the catheter near the entry site, which is coated in antimicrobial solution and holds the catheter in place after two to three weeks of insertion. | ||
Implanted central venous catheter (ICVC, port a cath) | The implanted central venous catheter (ICVC) is inserted into a vessel, body cavity, or organ and is attached to a reservoir or “port,” located under the skin. The ICVC is also referred to as a port a catheter or port a cath. A surgical procedure is required to insert the device, which is considered permanent. The device may be placed in the chest, abdomen, or inner aspect of the forearms. It is often better for body image. The ICVC can be accessed using a non-coring needle. A patient may return home with this type of CVC. | ||
Data source: Fulcher & Frazier, 2011; Perry et al., 2014 |
CVCs have specific protocols for accessing, flushing, disconnecting, and assessment. All health care providers require specialized training to care for, manage complications related to, and maintain CVCs as per agency policy. Never access or use a central line for IV therapy unless trained as per agency policy. For more information on CVC care and maintenance, see the suggested online reference list at the end of this chapter.
Health care providers should assess a patient with a central line at the beginning and the end of every shift, and as needed. For example, if the central line has been compromised (pulled or kinked), ensure it is functioning correctly. Each assessment should include:
See Table 8.4 for a list of complications, signs and symptoms, and interventions.
Complication | Signs and Symptoms | Interventions | |||||||||||||||
Pulmonary edema | Also known as fluid overload (circulatory overload); characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness, dyspnea, coughing up pinky frothy sputum. | Accurate fluid balance assessments, monitor electrolytes and vital signs, provide chest auscultation, elevate head of bed, administer oxygen and diuretic therapy | |||||||||||||||
Mechanical complications | A mechanical complication that mainly occurs during insertion of the CVC due to failure to correctly place the catheter, which may lead to asystolic cardiac arrest, bleeding, subcutaneous hematoma, hemothorax, catheter mal-position, or pneumothorax. These complications are usually detected at the time of insertion. | Treatment will be specific to the complication. | |||||||||||||||
Catheter-related bloodstream infection | Infection is a common complication of indwelling CVCs in patients with a vascular device and no apparent source for the bloodstream infection other than the device. Confirmed with one positive blood culture in patients who have had a vascular device implanted within the last 48 hours. Catheter-related bloodstream infection (CR-BSI) is caused by microorganisms that are introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV solution, leading to bacteremia or sepsis. A CR-BSI is a nosocomial preventable infection and an adverse event. Systemic: elevated temperature, flushed, headache, malaise, tachycardia, decreased BP, and additional signs and symptoms of sepsis | Strict hand-washing, aseptic technique for all procedures, close monitoring of vital signs, strict protocols for dressing, tubing and cap changes, blood cultures as required, IV antibiotic therapy, remove/replace catheter, prevent contamination of hub | |||||||||||||||
Infection at insertion site | Insertion site may become red, tender, swollen, or have purulent drainage. Monitor blood work and temperature. | Notify physician, clean area using strict aseptic technique, send C & S swab (swab for bacterial wound culture) as per policy | |||||||||||||||
Catheter-related thrombosis | Catheter-related thrombosis (CRT) is the development of a blood clot related to long-term CVC use. It mostly occurs in the upper extremities and can lead to further complications, such as pulmonary embolism, post-thrombotic syndrome, and vascular compromise. Symptoms include pain, tenderness to palpation, swelling, edema, warmth, erythema, and development of collateral vessels in the surrounding area. Most CRTs are asymptomatic, and prior catheter infections increase the risk for developing a CRT. | Routine flushing with positive pressure, vital signs, repositioning, IV bolus, notify physician, venogram/X-rays likely; will require anticoagulant therapy and possible removal of the CVC | |||||||||||||||
Air embolism | An air embolism is the presence of air in the vascular system and occurs when air is introduced into the venous system and travels to the right ventricle and/or pulmonary circulation. An air embolism can occur during CVC insertion, while catheter is in place, or at time of removal. Administration of up to 10 ml of air has been proven to have serious effects, and is sometimes fatal. Tiny air bubbles are tolerated by most patients. Signs and symptoms of an air embolism include sudden shortness of breath, continued coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom, lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and jugular venous distension. The effects of air embolism depend on the rate and volume of air introduced.
| Occlude source of air entry. Place patient in a Trendelenburg position on the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician promptly. To avoid an air embolism, ensure drip chamber is one-third to one-half filled, ensure all IV connections are tight, ensure clamps are used when IV system is not in use, and remove all air from IV tubing by priming prior to attaching to patient. | |||||||||||||||
Occlusions of CVC (mechanical or thrombus) | Occlusions may be mechanical (pinch-off syndrome, due to an internal pinching of the central line between the first rib and clavicle), caused by medication (unplanned/accidental precipitation in the IV line), or from parenteral nutrition (may leave a lipid residue inside the catheter). Thrombus formation (fibrin sheath around the tip of the catheter) may occur as soon as 24 hours after CVC is inserted. Thrombotic occlusions are responsible for approximately 58% of all occlusions. In addition to causing catheter dysfunction, thrombotic occlusions can lead to catheter-related thrombosis. Signs include sluggish flow rate, inability to flush or infuse medications, and frequent downstream occlusion alarms on the EID. | Follow agency-specific guidelines for managing various types of occlusions. Thrombolytic therapy may be initiated. Do not flush against resistance, flush well between medications, and always flush using positive pressure through a positive pressure cap. | |||||||||||||||
Damage to CVC line | CVCs may become broken or cracked. Assess for pinholes, cracks, or tears during routine care. Assess for drainage after routine care. Avoid using sharp objects around CVCs, and only use a needleless device when accessing a central line. | Clamp immediately and seal with a sterile, occlusive dressing to prevent an air embolism, bleeding, or a CR-BSI. The CVC may be repaired or replaced. Notify health care provider promptly. Repair should only be completed by a trained CVC specialist. | |||||||||||||||
Catheter migration | Patient may experience dysrhythmias caused by tip of the catheter moving from original position to an unwanted position. Migration may occur due to increased intrathoracic pressure due to coughing, change in body position, or physical movement (of the arms), sneezing, or weightlifting. | Call physician and stop all fluid infusions. You may need to pull back on tubing and X-ray CVC again for placement confirmation. Tape catheter securely using tape and devices. Do not pull on central lines; prevent IV lines from being caught on other equipment. | |||||||||||||||
Data source: Baskin et al., 2009; BCIT, 2015a; Brunce, 2003; Fraser Health Authority, 2014; Perry et al., 2014; Prabaharan & Thomas, 2014 |
Critical Thinking Exercises
Patients are prescribed an IV solution (fluids) based on their electrolyte and fluid volume status. IV fluids are commonly categorized as colloids and crystalloids. Colloid solutions contain large molecules that cannot pass through semi-permeable membranes and are used to expand intravascular volume by drawing fluid from extravascular space via high osmotic pressure. Examples of colloid solutions are albumin, dextrans, and hydroxyethyl starches (Crawford & Harris, 2011). Crystalloid solutions contain solutes such as electrolytes or dextrose, which are easily mixed and dissolvable in solution. Crystalloids contain small molecules that flow easily across semi-permeable membranes, which allows for transfer from the bloodstream into the cells and tissues (Crawford & Harris, 2011). They may increase fluid volume in interstitial and intravascular space. Examples of crystalloid solutions are isotonic, hypotonic, and hypertonic solutions.
Isotonic solutions have an osomolality of 250 to 375 mOsm/L. Isotonic solutions have the same osmotic pressure as plasma, creating constant pressure inside and outside the cells, which causes the cells to remain the same (they will not shrink or swell) and does not cause any fluid shifts within compartments. Isotonic solutions are useful to increase intravascular volume, and are utilized to treat vomiting, diarrhea, shock, and metabolic acidosis, and for resuscitation purposes and the administration of blood and blood products. Examples of isotonic solutions include normal saline (0.9% sodium chloride), lactated Ringer’s solution, 5% dextrose in water (D5W), and Ringer’s solution. It is important to monitor patients receiving isotonic solutions for fluid volume overload (hypervolemia) (Crawford & Harris, 2011).
Hypotonic solutions have a lower concentration, or tonicity, of solutes and have an osomolality equal to or less than 250 mOsm/L. The infusion of hypotonic solutions lowers the osmolality within the vascular space and causes fluid to shift to the intracellular and interstitial space. Cells will swell but may also delete fluid within the vascular space. Examples of hypotonic solutions include 0.45% sodium chloride, 0.33% sodium chloride, 2.5% dextrose in water, and 0.2% sodium chloride. Monitor for hypovolemia and hypotension related to fluid shifting out of the vascular space, and do not administer to patients with increased intracranial pressure (ICP), as it may exacerbate cerebral edema. Use cautiously in patients with burns, liver failure, and traumas (Crawford & Harris, 2011).
Hypertonic solutions have a higher concentration, or tonicity, of solutes and have an osomolality equal to or greater than 375 mOsm/L. The osmotic pressure gradient draws water out of the intracellular space into the extracellular space. Examples of hypertonic solutions include D5W and 0.45% sodium chloride, D10W, and 3% sodium chloride. Hypertonic solutions may cause intravascular fluid volume overload and pulmonary edema, and they should not be used for an extended period of time. Hypertonic solutions should not be used in patients with heart or renal disease who are dehydrated (Crawford & Harris, 2011).
Although all IV fluids must be administered carefully, hypertonic solutions are additionally risky.
An order for IV fluids may be continuous or as a bolus, depending on the needs of the patient. IV solutions are available in 25 ml to 1000 ml bags. The frequency, duration, amount, and additives to solution must be ordered by a physician or nurse practitioner; for example, an order may be “give NS at 125 ml/hr.”
The most common types of solutions include normal saline (NS) and D5W. Patients may also have medications, such as potassium chloride, thiamine, and multivitamins, added to IV solutions. To discontinue an IV infusion, an order must be obtained from the physician or nurse practitioner (Perry et al., 2014).
When a peripheral vein has a cannula inserted, an extension tubing is connected to the hub on the cannula and flushed with normal saline to maintain patency of the cannula. Most peripheral intravenous cannulas will have extension tubing, a short, 20 cm tube with a positive fluid displacement/positive pressure cap attached to the hub of the cannula for ease of access and to decrease manipulation of the catheter hub (Vancouver Coastal Health, 2008). The extension tubing must be changed each time the peripheral catheter is changed. When the peripheral cannula is not in use, the extension tubing attached to the cannula is called a saline lock.
Intravenous fluids are administered through thin, flexible plastic tubing called an infusion set or primary infusion tubing/administration set (Perry et al., 2014). The infusion tubing/administration set connects to the bag of IV solution. Primary IV tubing is either a macro-drip solution administration set that delivers 10, 15, or 20 gtts/ml, or a micro-drip set that delivers 60 drops/ml. Macro-drip sets are used for routine primary infusions. Micro-drip IV tubing is used mostly in pediatric or neonatal care, when small amounts of fluids are to be administered over a long period of time (Perry et al., 2014). The drop factor can be located on the packaging of the IV tubing.
Primary IV tubing is used to infuse continuous or intermittent fluids or medication. It consists of the following parts:
IV solution bags should have the date, time, and initials of the health care provider marked on them to be valid. Add-on devices (e.g., extension tubing or dead-enders) should be changed every 96 hours, if contaminated when administration set is replaced, or as per agency policy. Intravenous solution and IV tubing should be changed if:
Primary and secondary administration sets (see Figure 8.4) should be changed regularly to minimize risk and prevent infection (CDC, 2011; Fraser Health Authority, 2014). Change IV tubing according to agency policy. Table 8.5 lists the frequency of IV tubing change.
Safety considerations:
| |||
Frequency of IV Tubing Change | Type of IV Tubing and Solution | ||
Every 72 -96 hours | Primary tubing with hypotonic, isotonic, or hypertonic continuous solution, when insertion site is changed, or when indicated by the type of solution or medication being administered. | ||
Every 24 hours | Secondary or intermittent IV solution or medication. Rationale: When an intermittent infusion is repeatedly disconnected and reconnected for infusion, there is increased risk of contamination at the catheter hub, needleless connector, and the male Luer end of the administration set, potentially increasing risk for CR-BSI. | ||
Every 24 hours | Infusions containing fat emulsions (IV solutions combined with glucose and amino acids infused separately or in a 3 in 1 admixture). Example: Total parenteral nutrition (TPN). | ||
4 hours or 4 units, whichever comes first, or between products | Blood and blood products | ||
Data source: CDC, 2011 |
To ensure therapeutic effectiveness of IV fluids, a constant, even flow is necessary to prevent complications from too much or too little fluid. A physician must order a rate of infusion for IV fluids or for medications. The rate of infusion for medications (given via a secondary or primary infusion) can be found in the Parenteral Drug Therapy Manual (PDTM). If an order for IV fluids is “to keep vein open” (TKVO), the minimum flow rate is 20 to 50 ml per hour, or according to physician’s orders (Fraser Heath Authority, 2014).
A health care provider is responsible for regulating and monitoring the amount of IV fluids being infused. IV fluid rates are regulated in one of two ways:
An IV pump must be used for:
To calculate the drops per minute for an infusion by gravity, follow the steps in Table 8.6.
Steps | Additional Information | ||||||||
1. Verify the physician order. | An order may read: Example 1. Give NS IV 125 ml/hr Example 2. Give 1000 ml of NS IV over 8 hours. | ||||||||
2. Determine the drop factor on the IV administration set. | The drop factor is the amount of drops (gtts) per minute. IV tubing is either macro tubing (10, 15, or 20 gtts/min) or micro tubing (60 gtts/min). The drop factor (or calibration of the tubing) is always on the packaging of the IV tubing. | ||||||||
3. Complete the calculation using the formula. | Use the formula:
To calculate ml/hr, divide 1000 ÷ 8 = 125 ml/hr. Example: Infuse IV NS at 125 ml/hr. IV tubing drop factor is 20 gtts/min
| ||||||||
4. Regulate IV infusion using the roller clamp. | Observe and count the drips in the drip chamber and regulate for 42 gtts/min (one full minute). Alternatively, divide 42 by 4 (rounded down from 10.4 to 10 gtts/min) to count for 15 seconds. The gtts/min should be assessed regularly to ensure the IV is infusing at the correct rate (e.g., every 1 to 2 hours, if the patient accidentally bumps the IV tubing, or if a patient returns from another department). | ||||||||
Data source: Fulcher & Frazier, 2007; Perry et al., 2014 |
When an infusion is by gravity, there are several factors that may alter the flow/infusion rate (Fulcher & Frazier, 2007). In addition to regulating the flow rate, assess the IV system to ensure these factors are not increasing or decreasing the flow of the IV solution. These factors are listed in Table 8.7.
Factors | Additional Information | ||
Tube occlusion | May occur if the tubing is kinked or bent. Tubing may become kinked if caught under the patient or on equipment, such as beds and bed rails. | ||
Vein spasms | Irritating or chilled fluids (fluids stored in the fridge) may cause a reflex action that causes the vein to go into spasm at or near the intravenous infusion site. If fluids or medications are chilled, bring to room temperature prior to infusion. | ||
Height of the fluid container | The IV tubing drip chamber should be approximately 3 feet above IV insertion site. | ||
Location/position of IV cannula | If the cannula is located in an area of flexion (bend of an arm), the IV flow may be interrupted when the patient moves around. To avoid this issue, replace IV cannula. | ||
Infiltration or extravasation | If the cannula punctures the vein, the fluid will leak into the surrounding tissue and slow or stop the flow, and swelling will develop. | ||
Accidental touching/bumping of the control clamp or raising arm above heart level | Instruct the patient not to touch the roller clamp and to take care not to bump the clamp, as this may accidentally change the flow rate. Instruct patient to keep hand/arm below heart level; an elevated hand/arm will slow or stop an infusion running by gravity. | ||
Needle or cannula gauge/diameter | The smaller the needle or cannula, the slower the fluid will flow. | ||
Data source: Fulcher & Frazier, 2007; Perry et al., 2014 |
All patients with IV fluid therapy (PIV and CVC) are at risk for developing IV-related complications. The assessment of an IV system (including the IV site, tubing, rate, and solution) (see Figure 8.6) often depends on what is being infused, the patient’s age and medical condition, type of IV therapy (PIV or CVC), and agency policy. Generally, an IV system should be assessed as described in Checklist 65.
Critical Thinking Exercises
Primary and secondary IV tubing and add-on devices (extension tubing) must be primed with IV solution to remove air from the tubing. Priming refers to placing IV fluid in IV tubing to remove all air prior to attaching the IV tube to the patient. IV tubing is primed to prevent air from entering the circulatory system. An air embolism is a potential complication of IV therapy and can enter a patient’s blood system through cut tubing, unprimed IV tubing, access ports, and drip chambers with too little fluid (Perry et al., 2014). It is unknown how much air will cause death, but deaths have been reported with as little as 10 ml of air. The best way to avoid air bubbles in IV tubing is to prevent them in the first place (Perry et al., 2014). New IV tubing may also be required if leaking occurs around the tube connecting to the IV solution, if the tubing becomes damaged, or if it becomes contaminated. Checklist 66 outlines the process of priming IV tubing.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | ||||
Safety considerations:
| ||||
Steps | Additional Information | |||
1. Perform hand hygiene. | This step prevents the transmission of microorganisms. | |||
2. Check order to verify solution, rate, and frequency. | This ensures IV solution is correct and helps prevent medication error. | |||
3. Gather supplies. | You will need IV solution, primary IV tubing, time label, change label, alcohol swab, and basin or sink. | |||
4. Remove IV solution from outer packaging and gently squeeze. | Tear the perforated corner of the outer packaging; check colour, clarity, and expiration date. | |||
5. Remove primary IV tubing from outer packaging. | ||||
6. Move the roller clamp about 3 cm below the drip chamber and close the clamp. | ||||
7. Remove the protective cover on the IV solution port and keep sterile. Remove the protective cover on the IV tubing spike. | Be careful and do not contaminate the spike. | |||
8. Without contaminating the solution port, carefully insert the IV tubing spike into the port, gently pushing and twisting. | ||||
9. Hang bag on IV pole. | The IV bag should be approximately one metre above the IV insertion site. | |||
10. Fill the drip chamber one-third to one-half full by gently squeezing the chamber. Remove protective cover on the end of the tubing and keep sterile. | Filling the drip chamber prevents air from entering the IV tubing. | |||
11. With distal end of tubing over a basin or sink, slowly open roller clamp to prime the IV tubing. Invert backcheck valve and ports as the fluid passes through the tubing. Tap gently to remove air and to fill with fluid. | Inverting and tapping the access ports and backcheck valve helps displace and remove air when priming the IV tubing. | |||
12. Once IV tubing is primed, check the entire length of tubing to ensure no air bubbles are present. | This step confirms that air is out of the IV tubing. | |||
13. Close roller clamp. Cover end with sterile dead-ender or sterile protective cover. Hang tubing on IV pole to prevent from touching the ground. | Keep the distal end sterile prior to connecting IV to patient. | |||
14. Label tubing and IV bag with date, time, and initials. | Label IV solution bag as per agency policy. Do not write directly on the IV bag. | |||
15. Perform hand hygiene. | This reduces the transmission of microorganisms. | |||
Data source: Fulcher & Frazier, 2007; Perry et al., 2014. |
IV solutions are considered sterile for 24 hours. An IV solution may be changed if the physician’s order changes, if an IV solution infusing at TKVO is expired after 24 hours, or if the IV solution becomes contaminated. To change an IV solution bag, follow Checklist 67.
Checklist 68 describes how to change the IV tubing administration set and IV solution at the same time.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | ||||
Steps | Additional Information | |||
1. Verify physician orders for the type of solution, rate, and duration. Collect necessary supplies. | This step verifies the patient’s need for IV fluids/medications. It also confirms the correct rate and solution for patient safety. | |||
2. Perform hand hygiene. | Hand hygiene prevents the transmission of microorganisms. | |||
3. Identify yourself, identify the patient using two identifiers, and explain the procedure to the patient. | Proper identification of patient prevents errors. | |||
4. Prime new administration set using a new IV solution bag and new IV tubing. | IV solutions are considered a medication. Prime as per Checklist 66. Keep distal protective cap attached to IV tubing to ensure sterility of distal end. Label IV solution and IV tubing as per agency policy. | |||
5. Hang new administration set (primed primary line and IV solution) on IV pole. | This prepares the equipment and adheres to the principles of aseptic technique. | |||
6. Clamp old IV administration set. Remove IV tubing if on an EID. | Stop the flow of infusion during tubing and solution change. | |||
7. Clean the connection between the distal end of old IV tubing and the positive pressure cap. Scrub the area for 15 seconds and let it dry for 30 seconds. | Proper disinfection of equipment decreases bacterial load and prevents infections. | |||
8. Remove the protective cap on the distal end of the new IV administration set. | ||||
9. Carefully disconnect the old tubing from the positive pressure cap and insert the new IV tubing into the positive pressure cap attached to the extension tubing. | ||||
10. Open the roller clamp on the new tubing to regulate flow rate, or insert new tubing into the EID and restart IV rate. | This step ensures the IV solution is infusing at the correct rate. | |||
11. Check IV site for patency, and signs and symptoms of phlebitis. | IV site should be free from redness, swelling, and pain. Dressing on IV site should be dry and intact. | |||
12. Discard old supplies and perform hand hygiene. | This step prevents the spread of microorganisms. | |||
13. Document procedure as per agency policy. | Document the date and time of IV tubing and solution change. | |||
Data source: BCIT, 2015b; Fulcher & Frazier, 2007; Perry et al., 2014 |
Critical Thinking Exercises
A saline lock (SL), also known as a heparin lock, is a peripheral intravenous cannula connected to extension tubing with a positive pressure cap (see Figure 8.7). This device allows easy access to the peripheral vein for intermittent IV fluids or medications (Perry, et al., 2014). The saline lock is “flushed” or filled with normal saline to prevent clotting when not in use. To use an SL, the cannula is flushed with 3 to 5 ml of normal saline to assess patency. After the saline lock is used, the cannula is flushed again with 3 to 5 ml of normal saline or heparin to “lock” the saline in the cannula in order to keep it patent. Once the saline lock is inserted, it can be left in a vein for up to 72 hours or as per agency policy. Saline locks are usually inserted in the arm or hand. If a saline lock is removed, the extension tubing and positive pressure cap are also changed (Vancouver Coastal Health, 2012).
A saline lock can be used for continuous and intermittent short-term IV therapy. Flushing is performed:
A saline lock must be flushed in a specific manner to prevent blood being drawn into the IV catheter and occluding the device between uses. Checklist 69 describes the process of flushing an SL.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | ||||
Safety considerations:
| ||||
Steps | Additional Information | |||
1. Perform hand hygiene; gather supplies. | You will need alcohol swabs, 3 to 5 ml syringe prefilled with 0.9% normal saline, clean gloves. | |||
2. Compare MAR to patient’s wristband, identify patient using two identifiers, and explain procedure to patient. | Follow agency policy for proper patient identification. | |||
3. Clean work surface with CaviWipes and let dry. | This prevents the spread of microorganisms. | |||
4. Perform hand hygiene and apply clean gloves. | This prevents and minimizes the spread of microorganisms. | |||
5. Assess IV site for signs and symptoms of phlebitis. | If IV site is red, tender, or swollen, the SL needs to be discontinued; do not flush. | |||
6. Scrub the top of the positive pressure cap for 15 seconds and let dry for 30 seconds. | Aseptic technique is required for all IV procedures. All access ports must be disinfected to decrease the bacterial load prior to use. | |||
7. Open clamp on extension tubing. | Clamp must be open to flush the saline lock. | |||
8. If using a prefilled normal saline syringe for flushing, the air must be “purged” from the syringe. To remove air from a syringe, apply gentle pressure to the syringe plunger until a click, snap, or pop sound is heard. Next, remove the sterile dead-ender on the Luer lock end of the syringe, and remove the air by gently pushing the plunger upwards, keeping the syringe vertical. | Purging the air prevents it from being injected into the patient. Air should never be injected into a patient. | |||
9. Attach NS prefilled Luer lock syringe by twisting the syringe onto the positive pressure cap. Undo clamp on extension tubing. Inject 3 to 5 ml of solution using turbulent stop-start technique. Flush until visibly clear. Do not bottom out syringe (leave 0.2 to 0.5 ml in the syringe). | Turbulent stop-start flush ensures full flushing of the catheter. Bottoming out the saline syringe with the plunger can cause reflux of fluid back into the catheter. If resistance is felt, do not force flush. | |||
10. Remove syringe from positive pressure cap; THEN clamp the extension tubing. | Always clamp after removing syringe from the positive pressure cap. Positive displacement occurs when the syringe is disconnected from the positive pressure cap. Clamp the extension tubing as close to the IV site as possible to prevent negative fluid displacement and accidental aspiration of blood at the catheter tip. | |||
11. Wipe top of the positive pressure cap with an alcohol swab to remove fluid residue. | Moisture promotes the growth of microorganisms. | |||
12. Ensure dressing is dry and intact, and the extension tubing is properly secured with tape. | Properly secured extension tubing prevents accidental dislodgement of SL. | |||
13. Remove gloves; discard supplies and perform hand hygiene. | Proper disposal of equipment prevents the spread of microorganisms. | |||
14. Document procedure. | Document IV site assessment, location of PIV, procedure, date, and time. | |||
Data source: Perry et al., 2014; Vancouver Coastal Health, 2008 |
An SL can be converted to a continuous or intermittent IV to infuse fluids or medications. Prior to converting an SL to a continuous infusion, review the physician’s orders for type of solution, infusion rate, additives, and duration. IV solutions are considered a medication. Follow the seven rights × 3 when preparing IV solution. To convert a saline lock to a continuous IV, review Checklist 70.
Critical Thinking Exercises
A peripheral IV may be converted to a saline lock when a prescribed continuous IV therapy is switched to intermittent IV or a saline lock for future use. A physician’s order is required to stop a continuous infusion. Checklist 71 describes how to convert an infusion to a saline lock.
A peripheral IV (saline lock) may be discontinued if ordered by a physician or nurse practitioner; if the patient is discharged from a health care facility; if signs of phlebitis, infiltration, or extravasation occur; or if the saline lock is no longer required for fluids or medication (Fulcher & Fraser, 2007). Peripheral IV’s should be removed promptly when no longer needed to avoid a catheter-related bloodstream infection (CR-BSI), as well as unnecessary pain and trauma (Infusion Nurses Society, 2012). In general, saline locks are changed every 72 hours. If a patient has a peripheral IV in an area of flexion, the IV site should be replaced within 24 hours, or when the patient is stable. Other research shows that peripheral IV cannulas should not be routinely changed but replaced based on whether the site is functioning, the saline lock is required, the insertion site is patent, and/or the insertion site is a source of infection (CDC 2011; Infusion Nurses Society, 2011).
At times, a physician may order IV fluids to be discontinued but request to have the IV converted to saline lock. Be sure to assess the order for discontinuing an IV. Before removing an IV, consider the following:
Review the steps in Checklist 72 for removing a peripheral IV.
Critical Thinking Exercises
All health care practitioners who administer blood or blood products must complete specific training for safe transfusion practices and be competent in the transfusion administration process. Always refer to your agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions. These guidelines apply to adult patients only.
The transfusion of blood or blood products (see Figure 8.8) is the administration of whole blood, its components, or plasma-derived products. The primary indication for a red blood cell (RBC) transfusion is to improve the oxygen-carrying capacity of the blood (Canadian Blood Services, 2013). A health care provider order is required for the transfusion of blood or blood products. RBC transfusions are indicated in patients with anemia who have evidence of impaired oxygen delivery. For example, individuals with acute blood loss, chronic anemia and cardiopulmonary compromise, or disease or medication effects associated with bone marrow suppression may be candidates for RBC transfusion. In patients with acute blood loss, volume replacement is often more critical than the composition of the replacing fluids (Canadian Blood Services, 2013). Transfusions can restore blood volume, restore oxygen-carrying capacity of blood with red blood cells, and provide platelets and clotting factors. The most common type of blood transfusion is blood that is donated by another person (allogeneic). Autologous transfusion is the transfusion of one’s own blood (Perry et al., 2014).
Transfusion therapy is considered safe, and stringent precautions are followed in the collection, processing, and administration of blood and blood components. However, transfusions still carry risks such as incompatibility, human error, and disease transmission, and blood transfusion must be taken seriously at all times. Incompatibility can be decreased by using irradiated red blood cells or leukocyte-reduced blood. The majority of blood transfusion complications are a result of human error (Perry et al., 2014).
Compatibility testing is vital for all recipients of blood or blood products. Recipients must be transfused with an ABO group specific to their own blood type or ABO group-compatible. There are three types of blood typing systems: ABO, Rh, and human leukocyte antigen (HLA). For more information on these, refer to the online resources at the end of this chapter. It is vital to understand what types of blood groups are compatible for transfusions (Canadian Blood Services, 2013).
When administering blood and blood products, it is important to know the patient’s values and beliefs regarding blood products. Some groups of individuals, mainly Jehovah Witnesses, will refuse blood transfusions or blood products based on religious beliefs. These individuals will refuse transfusion of whole blood and primary blood components but may accept transfusion of derivatives of primary blood components such as albumins solutions, clotting factors and immunoglobulins. Always assess each individual preference to establish if a blood component is an acceptable treatment to manage their illness or condition (Canadian Blood Services, 2007).
When managing blood transfusions, it is important to prevent complications from occurring and to identify issues promptly to manage reactions effectively. Transfusion reactions (mild to life-threatening) may occur despite all safety measures taken. All transfusion reactions and transfusion errors must be reported to the hospital’s transfusion services (blood bank). It is imperative to know what signs and symptoms to look for, and to educate your patient on what to report and when to report potential transfusion reactions. Mild to severe reactions may include (Canadian Blood Services, 2011):
For more information on types of reactions, signs and symptoms, and treatments, review the article adverse events related to blood transfusions, or see the online resources at the end of this chapter. If patient has a blood transfusion reaction, always follow agency policy to manage mild to severe blood reactions. In general, if a reaction occurs, follow the steps outlined in Checklist 73.
In preparation for a blood or blood product transfusion (Alberta Health Services, 2015a, 2015b; Perry et al., 2014; Vancouver Coastal Health, 2008), the steps listed in Checklist 74 must be completed. These steps must be completed before obtaining the blood or blood product from the blood bank.
Checklist 75 provides steps to administering blood and blood products safely in the acute care setting.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | ||||
Safety considerations:
| ||||
Steps | Additional Information | |||
1. Verify physician orders and all preparation steps as listed in Checklist 74. | ||||
2. Assess or initiate venous access. | Appropriate needle gauge is based on clinical status of patient, urgency of transfusion, and venous access:
Transfusion set must be Luer-locked to a 2.0 ml maximum extension tubing, either directly to cannula or through a Max Plus positive pressure cap. | |||
3. Initiate primary infusion at TKVO. | Prime an IV line following Checklist 66.
Refer to blood product fact sheets for all other products. | |||
4. Complete and document cardiovascular assessments and initial vital signs. | Document any clinical sign or symptom that may be confused with a transfusion reaction (e.g., existing fever). | |||
5. Obtain products from the transfusion areas within 30 minutes of planned transfusion. | Plan for pickup or delivery of blood and blood products. Do not request blood or blood products if Steps 1 to 4 are not complete. | |||
6. Complete visual inspection of product. | Assess blood bag for any signs of leaks or contamination, such as clumping, clots, gas bubbles, or a purplish discoloration. Return to blood bank if blood bag contains any of the above signs. | |||
7. Initial verification: a. Compare the transfusion medical services (TMS) documentation with the patient record to verify:
b. Compare the TMS documentation with the product label attached to the product tab and verify:
| All verification numbers/information must match exactly. Must be completed by two trained staff members competent in blood transfusion administration process as set out by the agency. Confirm the patient blood type and Rh are compatible with the donor blood type and Rh. If there are any discrepancies, stop the process and contact the TMS for resolution and direction. Do not proceed. Ensure the blood product matches the physician’s orders (red blood cells or platelets). | |||
8 Administer pre-medications as ordered. | Medications must be administered through an IV infusion set, and the IV site cleared with 0.9% NS. | |||
9. Final verification (must be completed by the same two staff members as noted in Step 7). Compare the patient’s first and last name and unique identifier number using all of the following:
Only after recipient identification and product check is confirmed, invert product 5 to 10 times and insert spike of the blood administration set into the blood product container. | All verification numbers must match exactly. If there are any discrepancies, stop the process and contact the TMS for resolution and direction. Do not proceed. Patients who are alert and oriented should be asked to:
All identifying information attached to the blood bag must remain attached at least until completion of transfusion. | |||
10. Perform hand hygiene. Prime the blood product administration set:
| Do not remove the product from the presence of the patient; prime at bedside. If product is removed from bedside, the final verification process must be completed again. | |||
11. Initiate transfusion:
| Adults: Initiate red cells slowly (25 ml in the first 15 minutes). For all other blood transfusions, refer to the blood and product sheet as per your agency policy. Some agencies use an EID to administer blood transfusions. Always check agency policy prior to transfusion. For each and every unit:
Most transfusion reactions occur within first 15 minutes of a transfusion. Infusing small amounts of blood component initially minimizes volume of blood to which patient is exposed, thereby minimizing severity of reaction. | |||
12. Monitor:
| Vital signs must be monitored:
| |||
13. In the event of a transfusion reaction, stop the infusion. |
| |||
14. For additional units, repeat steps 6 to 12. | Follow the same process to ensure patient safety. | |||
15. Flush administration set with maximum of 50 ml of normal saline and re-establish IV or SL as per physician orders. | Flushing displaces any blood or blood product from the administration set. It is not necessary to flush between units of the same blood product. | |||
16. Discard waste in biohazard waste container. | This prevents the spread of biohazard waste. | |||
17. Complete all documentation as required by agency. | Documentation may include:
| |||
Data source: Alberta Health Services, 2015a, 2015b; Perry et al., 2014; Vancouver Coastal Health, 2008 |
Critical Thinking Exercises
Total parenteral nutrition (TPN), also known as parenteral nutrition (PN) is a form of nutritional support given completely via the bloodstream, intravenously with an IV pump. TPN administers proteins, carbohydrates, fats, vitamins, and minerals. It aims to prevent and restore nutritional deficits, allowing bowel rest while supplying adequate caloric intake and essential nutrients, and removing antigenic mucosal stimuli (Perry et al., 2014).
TPN may be short-term or long-term nutritional therapy, and may be administered on acute medical floors as well as in critical care areas. The caloric requirements of each patient are individualized according to the degree of stress, organ failure, and percentage of ideal body weight. TPN is used with patients who cannot orally ingest or digest nutrition (Triantafillidis & Papalois, 2014). TPN may be administered as peripheral parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins are usually the veins of choice because there is less risk of thrombophlebitis and vessel damage (Chowdary & Reddy, 2010). According to Chowdary & Reddy (2010), candidates for TPN are:
TPN is made up of two components: amino acid/dextrose solution and a lipid emulsion solution (see Figure 8.9). It is ordered by a physician, in consultation with a dietitian, depending on the patient’s metabolic needs, clinical history, and blood work. The amino acid/dextrose solution is usually in a large volume bag (1,000 to 2,000 ml), and can be standard or custom-made. It is often yellow in colour due to the multivitamins it contains. The ingredients listed on the bag must be confirmed by the health care provider hanging the IV bag. The solution may also include medication, such as insulin and heparin. The amino acid/dextrose solution is reviewed and adjusted each day based on the patient’s blood work. Lipid emulsions are prepared in 100 to 250 ml bags or glass bottles and contain the essential fatty acids that are milky in appearance. At times, the lipid emulsion may be added to the amino acid/dextrose solution. It is then called 3 in 1 or total nutrition admixture (Perry et al., 2014).
TPN is prepared by a pharmacy, where the calories are calculated using a formula, and is usually mixed for a 24-hour continuous infusion to prevent vascular trauma and metabolic instability (North York Hospital, 2013). TPN orders should be reviewed each day, so that changes in electrolytes or the acid-base balance can be addressed appropriately without wasting costly TPN solutions (Chowdary & Reddy, 2010).
TPN is not compatible with any other type of IV solution or medication and must be administered by itself. TPN must be administered using an EID (IV pump), and requires special IV filter tubing (see Figure 8.10) for the amino acids and lipid emulsion to reduce the risk of particles entering the patient. Agency policy may allow amino acids and lipid emulsions to be infused together above the filters. TPN tubing will not have any access ports and must be changed according to agency policy. Always review agency policy on setup and equipment required to infuse TPN.
A physician may order a total fluid intake (TFI) for the amount of fluid to be infused per hour to prevent fluid overload in patients receiving TPN. It is important to keep track of all the fluids infusing (IV fluids, IV medications, and TPN) in order to avoid fluid overload (Perry et al., 2014). Do not abruptly discontinue TPN (especially in patients who are on insulin) because this may lead to hypoglycemia. If for whatever reason the TPN solution runs out while awaiting another bag, hang D5W at the same rate of infusion while waiting for the new TPN bag to arrive (North York Hospital, 2013). Do not obtain blood samples or central venous pressure readings from the same port as TPN infusions. To prevent severe electrolyte and other metabolic abnormalities, the infusion rate of TPN is increased gradually, starting at a rate of no more than 50% of the energy requirements (Mehanna, Nankivell, Moledina, & Travis, 2009).
There are many complications related to the administration of TPN (Perry et al., 2014). Table 8.8 lists potential complications, rationale, and interventions.
Complication | Rationale and Interventions | ||
Catheter-related bloodstream infection (CR-BSI), also known as sepsis | CR-BSI, which starts at the hub connection, is the spread of bacteria through the bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high dextrose concentration of TPN. Symptoms include tachycardia, hypotension, elevated or decreased temperature, increased breathing, decreased urine output, and disorientation. Interventions: Strict adherence to aseptic technique with insertion, care, and maintenance; avoid hyperglycemia to prevent infection complications; closely monitor vital signs and temperature. IV antibiotic therapy is required. Monitor white blood cell count and patient for malaise. Replace IV tubing frequently as per agency policy (usually every 24 hours). | ||
Localized infection at exit or entry site | Due to poor aseptic technique during insertion, care, or maintenance of central line or peripheral line Interventions: Apply strict aseptic technique during insertion, care, and maintenance. Frequently assess CVC site for redness, tenderness, or drainage. Notify health care provider of any signs and symptoms of infection. | ||
Pneumothorax | A pneumothorax occurs when the tip of the catheter enters the pleural space during insertion, causing the lung to collapse. Symptoms include sudden chest pain, difficulty breathing, decreased breath sounds, cessation of normal chest movement on affected side, and tachycardia. Interventions: Apply oxygen, notify physician. Patient will require removal of central line and possible chest tube insertion. | ||
Air embolism | An air embolism may occur if IV tubing disconnects and is open to air, or if part of catheter system is open or removed without being clamped. Symptoms include sudden respiratory distress, decreased oxygen saturation levels, shortness of breath, coughing, chest pain, and decreased blood pressure. Interventions: Make sure all connections are clamped and closed. Clamp catheter, position patient in left Trendelenburg position, call health care provider, and administer oxygen as needed. | ||
Hyperglycemia | Related to sudden increase in glucose after recent malnourished state. After starvation, glucose intake suppresses gluconeogenesis by leading to the release of insulin and the suppression of glycogen. Excessive glucose may lead to hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin stimulation). This may cause fatty liver, increased CO2 production, hypercapnea, and respiratory failure. Interventions: Monitor blood sugar frequently QID (four times per day), then less frequently when blood sugars are stable. Follow agency policy for glucose monitoring with TPN. Be alert to changes in dextrose levels in amino acids and the addition/removal of insulin to TPN solution. | ||
Refeeding syndrome | Refeeding syndrome is caused by rapid refeeding after a period of malnutrition, which leads to metabolic and hormonal changes characterized by electrolyte shifts (decreased phosphate, magnesium, and potassium in serum levels) that may lead to widespread cellular dysfunction. Phosphorus, potassium, magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be life-threatening. High-risk patients include the chronically undernourished and those with little intake for more than 10 days. Patients with dysphagia are at higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has started. The shift of water, glucose, potassium, phosphate, and magnesium back into the cells may lead to muscle weakness, respiratory failure, paralysis, coma, cranial nerve palsies, and rebound hypoglycemia. Interventions: Rate of TPN should be based on the severity of undernourishment for moderate- to high-risk patients. TPN should be initiated slowly and titrated up for four to seven days. All patients require close monitoring of electrolytes (daily for one week, then usually three times/week). Always follow agency policy. Blood work may be more frequent depending on the severity of the malnourishment. | ||
Fluid excess or pulmonary edema | Signs and symptoms include fine crackles in lower lung fields or throughout lung fields, hypoxia (decreased O2 sats). Interventions: Notify primary health care provider regarding change in condition. Patient may require IV medication, such as Lasix to remove excess fluids. A decrease or discontinuation of IV fluids may also occur. Raise head of bed to enhance breathing and apply O2 for oxygen saturation less than 92% or as per agency protocol. Monitor intake and output. Pulmonary edema may be more common in the elderly, young, and patients with renal or cardiac conditions. | ||
Data source: Chowdary & Reddy, 2010; Mehanna et al., 2009; O’Connor, Hanly, Francis, Keane, & McNamara, 2013; Perry et al., 2014 |
A patient on TPN must have blood work monitored closely to prevent the complications of refeeding syndrome. Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals will have a TPN protocol to follow for blood work. Common blood work includes CBC (complete blood count), electrolytes (with special attention to magnesium, potassium, and phosphate), liver enzymes (total and direct bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], gamma-glutamyl transferase [GGT], total protein, albumin), and renal function tests (creatinine and urea). Compare daily values to baseline values, and investigate and report any rapid changes in any values (Chowdary & Reddy, 2010; Perry et al., 2014). Table 8.9 outlines a plan of care when a patient is receiving TPN.
Assessment | Additional Information | ||
CVC/peripheral IV line | Intravenous line should remain patent, free from infection. Dextrose in TPN increases risk of infection. Assess for signs and symptoms of infections at site (redness, tenderness, discharge) and systemically (fever, increased WBC, malaise). Dressing should be dry and intact. | ||
Daily or biweekly weights | Monitor for evidence of edema or fluid overload. Over time, measurements will reflect weight loss/gain from caloric intake or fluid retention. | ||
Capillary or serum blood glucose levels | QID (4 times a day) capillary blood glucose initially to monitor glycemic control, then reduce monitoring when blood sugars are stable or as per agency policy. May be done more frequently if glycemic control is difficult. Indicates metabolic tolerance to dextrose in TPN solution and patient’s glycemic status. | ||
Monitor intake and output | Monitor and record every eight hours or as per agency policy. Monitor for signs and symptoms of fluid overload (excessive weight gain) by completing a cardiovascular and respiratory assessment. Assess intakes such as IV (intravenous fluids), PO (oral intake), NG (nasogastric tube feeds). Assess outputs: NG (removed gastric content through the nasogastic tube), fistula drainage, BM (liquid bowel movements), colostomy/ileostomy drainage, closed suction drainage devices (Penrose or Jackson-Pratt drainage) and chest tube drainage. | ||
Daily to weekly blood work | Review lab values for increases and decreases out of normal range. Lab values include CBC, electrolytes, calcium, magnesium, phosphorus, potassium, glucose, albumin, BUN (blood urea nitrogen), creatinine, triglycerides, and transferrin. | ||
Mouth care | Most patients will be NPO. Proper oral care is required as per agency policy. Some patients may have a diet order. | ||
Vital signs | Vital signs are more frequently monitored initially in patients with TPN. | ||
Data source: BCIT, 2015a; Perry et al., 2014 |
TPN may be administered in the hospital or in a home setting. Generally, patients receiving TPN are quite ill and may require a lengthy stay in the hospital. The administration of TPN must follow strict adherence to aseptic technique, and includes being alert for complications, as many of the patients will have altered defence mechanisms and complex conditions (Perry et al., 2014). To administer TPN, follow the steps in Checklist 76.
Critical Thinking Exercises
Infusion therapy is a common treatment in the hospital setting, and vital for patient recovery. The safe management of IV equipment and procedures related to IV therapy is an essential skill for safe patient care. This chapter reviewed the skills necessary to care for a patient receiving IV therapy, and the benefits and complications related to peripheral intravenous therapy, central venous catheters, blood and blood products, and TPN.
Key Takeaways
Alberta Health Services. (2015a). Transfusion of blood and blood components. Retrieved on July 15, 2015, from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-policy-ps-59.pdf
Alberta Health Services. (2015b). Transfusion of blood and blood components — Acute adult. Retrieved on July 15, 2015, from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-adult-acute-procedure-ps-59-01.pdf
ATI. (2015). Discontinuing a peripheral intravenous line. ATI Nursing Education. Intravenous Therapy. Retrieved on Oct 10, 2015 from http://atitesting.com/ati_next_gen/skillsmodules/content/iv-therapy/equipment/discontinuing-iv.html
Baskin, J. L., Pui, C. H., Reiss, U., Wilimas, J. A., Metzger, L. M., Ribeiro, R. C., & Howard, S. C. (2009). Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet, 374(9684), 159. doi: 10.1016/S0140-6736(09)60220-8
British Columbia Institute of Technology (BCIT). (2015a). CVC complications worksheet: NURS 3020. BCIT BSN program.
British Columbia Institute of Technology (BCIT). (2015b). Checklist: IV tubing administration set and IV solution change. NURS 2020. BCIT BSN program.
Brunce, M. (2003). Troubleshooting central lines. Retrieved on Aug 28, 2015, from http://www.modernmedicine.com/modern-medicine/content/troubleshooting-central-lines
Canadian Blood Services (2007). Blood Administration. Retrieved on Nov. 6, 2015 from http://www.transfusionmedicine.ca/sites/transfusionmedicine/files/PDF/CBC_CGT_09.pdf
Canadian Blood Services. (2011). Clinical guide to transfusions. Adverse reactions. Retrieved on July 9, 2015, from http://www.transfusionmedicine.ca/sites/transfusionmedicine/files/articles/CGTTChapter10_MAY2011_FINAL.pdf
Canadian Blood Services. (2013). Clinical guide to transfusions. Blood components. Retrieved on July 9, 2015, from http://www.transfusionmedicine.ca/sites/transfusionmedicine/files/articles/CGTTChapter2_MAR2013_FINAL.pdf
Centers for Disease Control. (2011). Guidelines for the prevention of intravascular catheter related infections. Retrieved on July 5, 2015, from http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Chowdary, K. V. R., & Reddy, P. N. (2010). Parenteral nutrition: Revisited. Indian Journal of Anaethestic, 54(2), 95-103. doi: 10.4103/0019-5049.63637
Crawford, A., & Harris, H. (2011). IV fluids: What nurses need to know. Nursing 2015, 41(5), 30-38. Retrieved on July 9, 2015, from http://journals.lww.com/nursing/Fulltext/2011/05000/I_V__fluids_What_nurses_need_to_know.10.aspx?WT.mc_id=HPxADx20100319xMP
Fraser Health. (2007). Central venous catheters in adult patients. A self-learning module. Retrieved on Oct 10, 2015, from https://www.fraserhealth.ca/media/CentralVenousCatheters.pdf
Fraser Health Authority. (2014). Clinical practice guidelines: Intravenous therapy. Retrieved on July 2, 2015, from http://physicians.fraserhealth.ca/media/2014%2005%2015%20IV%20Therapy%20CPG%20FINAL.pdf
Fulcher, E. M., & Fraser, M. S. (2007). Introduction to intravenous therapy for health professionals. St Louis, MO: Elsevier.
Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1). Retrieved on July 2, 2015, from http://www.ins1.org/i4a/ams/amsstore/category.cfm?product_id=192
Infusion Nurses Society. (2012). INS Position paper: Recommendations for frequency of assessment of the short peripheral catheter site. Journal of infusion nursing, 35(5), 290 -292.
McCallum L., & Higgins, D. (2012). Care of peripheral venous cannula sites. Nursing times, 108(34-35), 12-15.
Mehanna, H., Nankivell, P. C., Moledina, J., & Travis, J. (2009). Refeeding syndrome — awareness, prevention and management. Head and Neck Oncology, 1(4). doi: 10.1186/1758-3284-1-4
North York Hospital. (2013). Care of the patient receiving total parenteral nutrition (TPN). Retrieved on July 6, 2015, from
http://www.nygh.on.ca/cernercbt/files%5CCONTENT_Day_2%5CTPN%202013%5CTPN%20learning%20pkg%20revised%20July%202013.pdf
O’Connor, A., Hanly, A. M., Francis, E., Keane, N., & McNamara, D. (2013). Catheter associated blood stream infections in patient receiving parenteral nutrition: A prospective study of 850 patients. Journal of Clinical Medical Research, 5(1),18-21. doi: 10.4021/jomr1032w
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.
Phillips, L. D. (2005). Manual of IV therapies. Philadelphia, PA: F.A. Davis Company.
Prabaharan, B., & Thomas, S. (2014). Spontaneous migration of central venous catheter tip following extubation. Saudi J Anaesth, 8(1): 131–133. doi: 10.4103/1658-354X.125975
Safer Healthcare Now. (2012). Interventions. Retrieved on July 9, 2015, from: http://www.patientsafetyinstitute.ca/en/toolsResources/pages/interventions-default.aspx
Triantafillidis, J. K., & Papalois, A. E. (2014). The role of total parenteral nutrition in inflammatory bowel disease: Current aspects. Scandinavian Journal of Gastroenterology, 49(1), 3-14. doi: 10.3109/00365521.2013.860557.
Vancouver Coastal Health. (2008). Administration of blood components and blood products. Vancouver, BC: Vancouver Health Authority.
Vancouver Coastal Heath. (2012). Saline locks: Care and maintenance. Vancouver, BC: Vancouver Health Authority.
Waitt, C., Waitt, P., & Pirmohamed, M. (2004). Intravenous therapy. Postgraduate Medicine, 80(939), 1-6. doi: 10.1136/pmj.2003.010421
Blood glucose monitoring allows people with diabetes to monitor their blood glucose levels and manage their condition accordingly.
Type 1 diabetes usually develops in childhood or adolescence and used to be called juvenile-onset diabetes. It occurs when the beta cells of the pancreas are destroyed by the immune system and no longer produce insulin, or produce very little insulin. People with this form of diabetes need injections of insulin every day in order to control the levels of glucose in their blood. If they do not have access to insulin, they will die. There is no known way to prevent type 1 diabetes.
Type 2 diabetes used to be called non-insulin-dependent diabetes or adult-onset diabetes. It accounts for at least 90% of all cases of diabetes and can occur at any age. With type 2 diabetes, the body does not make enough insulin or does not respond well to the insulin it makes. Either or both of these characteristics — relative insulin deficiency and insulin resistance — may be present at the time diabetes is diagnosed.
Type 2 diabetes may remain undetected for many years, and the diagnosis is often made when a complication appears or a routine blood or urine glucose test is done. It is often, but not always, associated with overweight or obesity, which itself can cause insulin resistance and lead to high blood glucose levels. People with type 2 diabetes can often initially manage their condition through exercise and diet. However, over time most people will require oral drugs and or insulin.
Gestational diabetes is a form of diabetes that develops in women during pregnancy and disappears after delivery. Gestational diabetes affects about 4% of all pregnancies and increases the risk of developing type 2 diabetes.
Other specific types of diabetes also exist, and more information can be found at the Canadian Diabetes Association website.
People with diabetes can manage their disease by monitoring their blood glucose levels. To measure blood glucose levels, blood is obtained through a skin puncture using a specified needle system, which is less painful and invasive than venipuncture. The ease of this skin puncture method makes it possible for patients to perform this procedure themselves.
In the hospital setting, a blood glucose machine (glucometer) is used to provide an accurate blood glucose level in less than a minute using a reagent strip with a drop of blood dropped or wicked onto a new, dry, specifically indicated portion of the reagent strip. These machines must be regularly calibrated according to agency policy, and each machine should be cleaned between use on different patients.
Ensure that you read and understand the manufacturer’s instructions and your agency policy for the blood glucose monitoring machines used in your clinical setting.
Learning Objectives
People with diabetes require regular monitoring of their blood glucose to help them achieve as close to normal blood glucose levels as possible for as much of the time as possible. The benefits of maintaining a blood glucose level that is consistently within the range of 4-7 mmol/L will reduce the short-term, potentially life-threatening complications of hypoglycemia as well as the occurrence rate and severity of the long-term complications of hyperglycemia.
Patients in the hospital setting are likely to have inconsistent blood glucose levels as they are affected by changes in diet and lifestyle, surgical procedures, and the stress of being in a hospital. The physician will prescribe how regularly the blood glucose should be monitored. In acute situations, a sliding-scale treatment for insulin will be individually prescribed per patient. The medication administration record (MAR) or sliding scale will provide directions for the amount of medication to be given based on the blood glucose reading.
It is usually the responsibility of the nurse to perform blood glucose readings. As with any clinical procedure, ensure that you understand the patient’s condition, the reason for the test, and the possible outcomes of the procedure. Prior to performing a blood glucose test, ensure that you have read and understood the manufacturer’s instructions and your agency’s policy for the blood glucose monitoring machines (see Figure 9.1) used in your clinical setting, as these vary. It is also important that you determine the patient’s understanding of the procedure and the purpose for monitoring blood glucose level. Before you begin, you should also determine if there are any conditions present that could affect the reading. For example, is the patient fasting? Has the patient just had a meal? Is the patient on any medications that could affect the reading (e.g., anticoagulants)? In these situations, draw on your knowledge and understanding of diabetes, the medication you are administering, the uniqueness of your patient, and the clinical context. Use your knowledge and critical thinking to make a clinical judgment.
Inspect the area of skin that will be used as the puncture site and ask the patient if they are in agreement with the site you have identified to use for the skin puncture. Your patient may have a preference for the puncture site. For example, some patients prefer not to use a specific finger for the skin puncture. Or a particular site may be contraindicated. For example, you shouldn’t use the hand on the same side as a mastectomy.
Patients who do their own blood glucose testing at home may prefer to handle the skin-puncturing device themselves and continue self-testing while they are in the hospital.
Checklist 77 outlines the steps for taking a skin-puncture blood sample and using a blood glucose monitor (glucometer) to measure a patient’s blood glucose level.
Many nursing resources are from the United States, where glucose values are reported as mg/dl. Canadian laboratories use the international system of units (SI), which are mmol/L. Therefore, it is important to convert your patient’s laboratory values to SI units. For glucose, divide the mg/dl by 18 to find the comparable SI unit (e.g., 65 mg/dl = 3.61 mmol/L). This conversion chart shows specific conversions.
The concerns listed in Table 9.1 must be attended to and reported immediately to the relevant health care provider. Please consult hospital/unit-specific recommendations for exact values. The concerns and actions in Table 9.1 are guidelines only.
Concern | Action |
Blood sugar outside “acceptable range” (<2.2 mmol/L or >20 mmol/L) | Repeat capillary test to confirm, and report if reading remains out of range. |
Blood sugar <2.2 mmol/L or >20 mmol/L | Order a stat blood glucose (venous sample) by laboratory staff and initiate hypoglycemia or hyperglycemia protocol according to agency policy. |
Blood sugar <4 mmol/L | Initiate hypoglycemia protocol according to agency policy. |
Preoperative blood sugar <4 mmol/L or >20 mmol/L | Call physician. |
Post-operative blood sugar >13.5 mmol/L (acceptable post-operative range = 8-13 mmol/L) | Test urine for ketones. If positive, monitor urine ketones every 4 hours. |
Data source: BCIT, 2015 |
Critical Thinking Exercises
The overlapping symptoms of hypo- and hyperglycemia (e.g., hunger, sweating, trembling, confusion, irritability, dizziness, blurred vision) make the two conditions difficult to distinguish from one another (Paradalis, 2005). Since the treatment is different for each condition, it is critical to test the patient’s blood glucose when symptoms occur. The risk factors that may have led to the condition, and the recent medical history of the patient also help to determine the cause of symptoms.
Hypoglycemia is a condition occurring in diabetic patients with a blood glucose of less than 4 mmol/L. If glucose continues to remain low and is not rectified through treatment, a change in the patient’s mental status will result. Patients with hypoglycemia become confused and experience headache. Left untreated, they will progress into semi-consciousness and unconsciousness, leading rapidly to brain damage. Seizures may also occur.
Common initial symptoms of hypoglycemia include:
These symptoms will progress to mood or behaviour changes, vision changes, slurred speech, and unsteady gait if the hypoglycemia is not properly managed.
The hospitalized patient with type 1 or type 2 diabetes is at an increased risk for developing hypoglycemia. Potential causes of hypoglycemia in a hospitalized diabetic patient include:
Hypoglycemia is a medical emergency that must be treated immediately. An initial blood glucose reading may confirm suspicion of hypoglycemia. If you suspect that your patient is hypoglycemic, obtain a blood glucose level through skin puncture. A 15 g oral dose of glucose should be given to produce an increase in blood glucose of approximately 2.1 mmol/L in 20 minutes (Canadian Diabetes Association, 2013). Table 9.2 outlines an example of a protocol that may be used in the treatment of hypoglycemia.
Disclaimer: This is an example only of a hypoglycemia protocol. Always follow the protocol of your agency. | |||
Capillary Blood Gas (CBG) | Able to Swallow | Nil per Mouth with IV Access | Nil per Mouth with No IV Access |
≥ 4 mmol/L | No treatment necessary | No treatment necessary | No treatment necessary |
2.2-3.9 mmol/L | Give 15 g of glucose in the form of:
Note: Milk, orange juice, and glucose gels increase blood glucose (BG) levels more slowly and are not the best choice unless the above alternatives are not available. Repeat CBG every 15 to 20 minutes and repeat above if BG remains below 4 mmol/L. Once BG reaches 4 mmol/L, give patient 6 crackers and 2 tablespoons of peanut butter. If meal is less than 30 minutes away, omit snack and give patient meal when it is available. | Notify physician. Give 10-25 g (20-50 ml of D50W — dextrose 50% in water) of glucose intravenously over 1 to 3 minutes, OR as per agency policy. Repeat CBG every 15 to 20 minutes until 4 mmol/L. Continue with BG readings every 30 minutes for 2 hours. | Notify physician. Give glucagon 1 mg subcutaneously (SC) or intramuscularly (IM). Position patient on side. Repeat CBG every 15 to 20 minutes. Give second dose of glucagon 1 mg SC or IM if BG remains below 4 mmol/L. |
≤ 2.2 mmol/L | Call lab for STAT BG level. Continue as above. | Call lab for STAT BG level. Continue as above. | Call lab for STAT BG level. Continue as above. |
Data source: Canadian Diabetes Association, 2013; Paradalis, 2005; Rowe et al., 2015; VCH 2009 |
Hyperglycemia occurs when blood glucose values are greater than 7 mmol/L in a fasting state or greater than 10 mmol/L two hours after eating a meal (Pardalis, 2005). Hyperglycemia is a serious complication of diabetes that can result from eating too much food or simple sugar; insufficient insulin dosages; infection, illness, or surgery; and emotional stress. Surgical patients are particularly at risk for developing hyperglycemia due to the surgical stress response (Dagogo-Jack & Alberti, 2002; Mertin, Sawatzky, Diehl-Jones, & Lee, 2007). Classic symptoms of hyperglycemia include the three Ps: polydipsia, polyuria, and polyphagia.
The common symptoms of hyperglycemia are:
Other symptoms include glycosuria, nausea and vomiting, abdominal cramps, and progression to diabetic ketoacidosis (DKA).
Potential causes of hyperglycemia in a hospitalized patient include:
Note that testing blood glucose levels too soon after eating will result in higher blood glucose readings. Blood glucose levels should be taken one to two hours after eating.
If hyperglycemia is not treated, the patient is at risk for developing DKA. This is a life-threatening condition in which the body produces acids, called ketones, as a result of breaking down fat for energy. DKA occurs when insulin is extremely low and blood sugar is extremely high.
DKA presents clinically with symptoms of hyperglycemia as above, Kussmaul respiration (deep, rapid, and laboured breathing that is the result of the body attempting to blow off excess carbon dioxide to compensate for the metabolic acidosis), acetone-odoured breath, nausea, vomiting, and abdominal pain (Canadian Diabetes Association, 2013). Patients in DKA also undergo osmotic diuresis. They pass large amounts of urine because of the high solute concentration of the blood and the body’s attempts to get rid of excess sugar.
DKA is treated with the administration of fluids and electrolytes such as sodium, potassium, and chloride, as well as insulin. Be alert for vomiting and monitor cardiac rhythm. Untreated DKA can be fatal.
Patients with hyperglycemia may also exhibit a non-ketotic hyperosmolar state, also known as hyperglycemic hyperosmolar syndrome (HHS). This is a serious diabetic emergency that carries a mortality rate of 10% to 50%. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream.
Further information on the treatment of DKA and HHS can be found on the Canadian Diabetes Association clinical guidelines website.
Critical Thinking Exercises
Blood glucose monitoring is an important procedure that allows people with diabetes to monitor their blood glucose level and manage their condition. Each blood glucose monitor is slightly different, and it is essential that you read and follow the manufacturer’s instructions for each monitor you are using.
When working with patients with diabetes, it is also important to be able to recognize and manage patients with hypoglycemia and hyperglycemia.
Key Takeaways
British Columbia Institute of Technology (BCIT). (2015). NURS 2020: Clinical techniques. Vancouver: BCIT.
Canadian Diabetes Association. (2013). Canadian diabetes association clinical practice guidelines expert committee. Clinical practice guidelines for the prevention and management of diabetes in Canada. Can J diabetes, 37(suppl 1):S1-S212.
Dagogo-Jack, S., & Alberti, K. G. (2002). Management of diabetes mellitus in surgical patients. Diabetes spectrum, 15(1), 44-48.
Hortensius, J., Slingerland, R. J., Kleefstra, N., Logtenberg, S. J. J., Groenier, K. H., Houweling, S. T., & Bilo, H. J. G. (2011). Self-monitoring of blood glucose: The use of the first or the second drop of blood. Diabetes care, 34(3), 556–560.
Mertin, S., Sawatzky, J., Diehl-Jones, W., & Lee, T. (2007). Roadblock to recovery: The surgical stress response. Dynamics, 18(1), 14-22.
Pagana, K., & Pagana, T. (2011). Mosby’s diagnostic and laboratory test reference (10th ed.). St Louis, MO: Mosby.
Pardalis, D. (2005). Diabetes: Treatment of hyper- and hypoglycemia. Retrieved on Nov 14, 2015, from Tech Talk: The national continuing education program for pharmacy technicians, http://www.canadianhealthcarenetwork.ca/files/2009/10/TTCE_Sept05_Eng.pdf
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.
Rowe, B. H., Singh, M., Villa-Roel, C., Leiter, L. A., Hramiak, I., Edmonds, M. L., & … Campbell, S. (2015). Acute management and outcomes of patients with diabetes mellitus presenting to Canadian emergency departments with hypoglycemia. Canadian Journal Of Diabetes, 39(1), 55-64. doi:10.1016/j.jcjd.2014.04.001
Vancouver Coastal Health (VCH). (2009). Hypoglycemia algorithm. Vancouver: Vancouver Coastal Health.
VCH & PHC Professional Practice. (2013). Capillary blood glucose monitoring using the Accu-Chek blood glucose meter. Vancouver: Vancouver Coastal Health & Providence Health Care.
Weiss Behrend, S., Kelley, K., & Randoloph, S. (2004). Measuring blood-glucose levels. In Gaylene, A. (2004). Delmar’s fundamental and advanced nursing skills (2nd ed.). Clifton Park, NY: Thomson Delmar Learning.
Patients in acute care and community settings often have various tubes and attachments to assist their recovery from surgeries, medical conditions, or procedures. Health care providers must understand how these devices work — their purpose, function, insertion, or removal — and how to prevent complications from these various tubes and attachments.
Learning Objectives
The following five principles apply to the care of drainage tubes. It is important that you remember these principles when you are working with patients who have drainage tubes.
1. Closed cavities of the body are sterile cavities. Insertion of any tube must be performed with adherence to the principles of sterile asepsis.
2. A portal of entry that comes into contact with a non-sterile surface immediately renders an otherwise sterile field non-sterile. When disconnecting drainage tubes, such as a urinary catheter or a T-tube, the ends must be kept sterile.
3. Gravity promotes the flow of drainage from a cavity. Keep drainage tubes and collection bags at a lower level than the cavity being drained. Position the tube so the drainage will not have to run upward.
4. Drainage will flow out of the tubing if the lumen is not occluded. Avoid kinks and coils in the tubing and watch that the person does not lie on the tubing. Do not clamp tubes without a doctor’s order.
5. Properly cleanse the site before accessing any tubing to reduce possible introduction of microorganisms into a cavity. Sometimes contrast media and radiopharmaceuticals are injected via the tubing. An alcohol swab may be used to clean the entry point prior to accessing the tubing.
The following four factors affect the flow of fluid through tubes.
1. Pressure difference
2. Diameter
3. Length
4. Viscosity
Caring for patients with multiple tubes and attachments can be challenging. Follow the guidelines in Table 10.1 to help you care for patients with tubes and attachments.
Guideline | Rationale |
Secure tubes to the skin with tape (non-allergenic or waterproof). A good method of taping is to loop the tape around the tubing, make a “neck” of tape, and secure the tape to the skin (except for nasogastric tubes). This allows some gentle moving of the tube without kinking and protects it from the danger of being pulled out. | When tension is applied to the tube, the stress will be taken by the tape rather than by the tube. |
Drainage bags should be secured to stretchers, patient gowns, etc., as appropriate. | This prevents undue stress on the drainage tube and/or accidental removal from the wound or body cavity. |
Connect tube to sterile tubing and drainage receptacle. Do not clamp tubing unless ordered. | This helps keep wound or body cavity sterile and promotes flow of drainage. |
To ensure continuous drainage, be sure tubing is not kinked, not caught in the bed rails, not underneath the patient, and free from tension when turning, etc. | Any kinks in tubing can stop drainage from the patient and cause further complications. |
Dressing around tube, if any, should be clean and dry. Sterile technique is used if it is necessary to change the dressing. | This avoids irritation from tube rubbing the skin or from excessive drainage. |
Record and report patency of tube and amount, colour, character, and odour of drainage. If an unusual situation occurs in your department (i.e., if the bag is full and must be emptied), call for help. If the contents of a drainage tube are spilled, the approximate amount must be reported. | This will help inform ward staff of an unusual situation that happened in your department. |
If you are unsure how to empty the container or how to close it after a spill, seek help. | Most drainage tubes must have the ends kept sterile. Always follow agency regulations on how to clean up a blood or body fluid spill. |
Data source: BCIT, 2015a |
Critical Thinking Exercises
A nasogastric (NG) tube is a flexible plastic tube inserted through the nostrils, down the nasopharynx, and into the stomach or the upper portion of the small intestine. Placement of NG tubes is always confirmed with an X-ray prior to use (Perry, Potter, & Ostendorf, 2014).
NG tubes are used to:
An NG tube used for feeding should be labelled. The tube is used to feed patients who may have swallowing difficulties or require additional nutritional supplements. These tubes are narrower and smaller bored than a Salem sump or Levine tube.
An NG tube can also remove gastric content, either draining the stomach by gravity or by being connected to a suction pump. In these situations, the NG tube is used to prevent nausea, vomiting, or gastric distension, or to wash the stomach of toxins.
The NG tube is fastened to the patient using a nose clip, and is taped and pinned to the patient’s gown to prevent accidental removal of the tube and to prevent the tube from slipping from the stomach area into the lungs.
When working with people who have nasogastric tubes, remember the following care measures:
Checklist 78 outlines the steps for inserting a nasogastric tube.
An NG tube should be removed if it is no longer required. The process of removal is usually very quick. Prior to removing an NG tube, verify physician orders. If the NG tube was ordered to remove gastric content, the physician’s order may state to “trial” clamping the tube for a number of hours to see if the patient tolerates its removal. During the trial, the patient should not experience any nausea, vomiting, or abdominal distension.
To review how to remove an NG tube, refer to Checklist 79.
Critical Thinking Exercises
Urinary elimination is a basic human function that can be compromised by illness, surgery, and other conditions. Urinary catheterization may be used to support urinary elimination in patients who are unable to void naturally. Urinary catheterization may be required:
Catheter-associated urinary tract infections (CAUTI) are a common complication of indwelling urinary catheters and have been associated with increased morbidity, mortality, hospital cost, and length of stay (Gould et al., 2009). Urinary drainage systems are often reservoirs for multidrug-resistant organisms (MDROs) and a source of the transmission of microorganisms to other patients (Gould et al., 2009). The most important risk factor for developing a CAUTI, a health care associated infection (HAI), is the prolonged use of a urinary catheter (Centers for Disease Control and Prevention [CDC], 2015). Urinary tract infections (UTIs) are the most commonly reported HAIs in acute care hospitals and account for more than 30% of all reported infections (Gould et al., 2009). Catheters in place for more than a few days place the patient at risk for a CAUTI. A health care provider must assess patients for signs and symptoms of CAUTIs and report immediately to the primary health care provider. Signs and symptoms of a CAUTI include:
The following are practices for preventing CAUTIs (Perry et al., 2014):
Urinary catheterization refers to the insertion of a catheter tube through the urethra and into the bladder to drain urine. Although not a particularly complex skill, urethral catheterization can be difficult to master. Both male and female catheterizations present unique challenges.
Having adequate lighting and visualization is helpful, but does not ensure entrance of the catheter into the female urethra. It is not uncommon for the catheter to enter the vagina. Leaving the catheter in the vagina can assist in the correct insertion of a new catheter into the urethra, but you must remember to remove the one in the vagina.
For some women, the supine lithotomy position can be very uncomfortable or even dangerous. For example, patients in the last trimester of pregnancy may faint with decreased blood supply to the fetus in this position. Patients with arthritis of the knees and hips may also find this position extremely uncomfortable. Catheterization may also be accomplished with the patient in the lateral to Sims position (three-quarters prone).
The male urinary sphincter may also be difficult to pass, particularly for older men with prostatic hypertrophy.
There are two types of urethral catheterization: intermittent and indwelling.
Intermittent catheterization (single-lumen catheter) is used for:
Indwelling catheterization (double- or triple-lumen catheter) is used for:
The steps for inserting an intermittent or an indwelling catheter are the same, except that the indwelling catheter requires a closed drainage system and inflation of a balloon to keep the catheter in place. Indwelling catheters may have two or three lumens (double or triple lumens). Double-lumen catheters comprise one lumen for draining the urine and a second lumen for inflating a balloon that keeps the catheter in place. Triple-lumen catheters are used for continuous bladder irrigation and for instilling medications into the bladder; the additional lumen delivers the irrigation fluid into the bladder.
Indwelling urinary catheters are made of latex or silicone. Intermittent catheters may be made of rubber or polyvinyl chloride (PVC), making them softer and more flexible than indwelling catheters (Perry et al., 2014). The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the tube. Recommended catheter size is 12 to 16 Fr for females, and 14 to 16 Fr for males. Smaller sizes are used for infants and children. The balloon size also varies with catheters: smaller for children (3 ml) and larger for continuous bladder irrigation (30 ml). The size of the catheter is usually printed on the side of the catheter port.
An indwelling catheter is attached to a drainage bag to allow for unrestricted flow of urine. Make sure that the urinary bag hangs below the level of the patient’s bladder so that urine flows out of the bladder. The bag should not touch the floor, and the patient should carry the bag below the level of the bladder when ambulating. To review how to insert an indwelling catheter, see Checklist 80.
Patients require an order to have an indwelling catheter removed. Although an order is required, it remains the responsibility of the health care provider to evaluate if the indwelling catheter is necessary for the patient’s recovery.
A urinary catheter should be removed as soon as possible when it is no longer needed. For post-operative patients who require an indwelling catheter, the catheter should be removed preferably within 24 hours. The following are appropriate uses of an indwelling catheter (Gould et al., 2009):
When a urinary catheter is removed, the health care provider must assess if normal bladder function has returned. The health care provider should report any hematuria, inability or difficulty voiding, or any new incontinence after catheter removal. Prior to removing a urinary catheter, the patient requires education on the process of removal, and on expected and unexpected outcomes (e.g., a mild burning sensation with the first void) (VCH Professional Practice, 2014). The health care provider should instruct patients to
Review the steps in Checklist 81 on how to remove an indwelling catheter.
Disclaimer: Always review and follow your hospital policy regarding this specific skill. | |||
Safety considerations:
| |||
Steps | Additional Information | ||
1. Verify physician orders, perform hand hygiene, and gather supplies. | Supplies include non-sterile gloves, sterile syringe (verify size of balloon on Foley catheter), waterproof pad, garbage bag, and cleaning supplies for perineal care. | ||
2. Identify patient using two identifiers. Create privacy and explain procedure for catheter removal. | This ensures you have the correct patient and follows agency policy on proper patient identification. | ||
3. Educate patient on catheter removal and post-urinary catheter care. | Patient must be informed of what to expect after catheter is removed and how to measure urine output, etc. | ||
4. Perform hand hygiene and set up supplies. | Raise bed to working height. Organize supplies. Position patient supine for easy access. | ||
5. Apply non-sterile gloves. | This reduces the transfer of microorganisms. | ||
6. Measure, empty, and record contents of catheter bag. Remove gloves, perform hand hygiene, and apply new non-sterile gloves. Remove catheter securement/anchor device. | Record drainage amount, colour, and consistency according to agency policy. Always change gloves after handling a urinary catheter bag. Removing catheter securement device provides easy access to catheter for cleaning and removing. | ||
7. Perform catheter care with warm water and soap or according to agency protocol. | This reduces the transfer of microorganisms into the urethra. | ||
8. Insert syringe in balloon port and drain fluid from balloon. Verify balloon size on catheter to ensure all fluid is removed from balloon. | A partially deflated balloon will cause trauma to the urethra wall and pain. | ||
9. Pull catheter out slowly and smoothly. Catheter should slide out slowly and smoothly. | If resistance is felt, stop removal and reattempt to remove the fluid from the balloon. Attempt removal again. If unable to remove the catheter, stop and notify physician. | ||
10. Wrap used catheter in waterproof pad or gloves. Unhook catheter tube from urinary bag. Discard equipment and supplies according to agency policy. | This prevents accidental spilling of urine from the catheter. | ||
11. Provide perineal care as required and reposition patient to a comfortable position. | This promotes patient comfort. | ||
12. Review post-catheter care, fluid intake, and expected and unexpected outcomes with patient. | Ensure patient has access to toilet, commode, bedpan, or urinal. Place call bell within reach. Ensure first void (urine output) is measured as per agency policy. Encourage patient to maintain or increase fluid intake to maintain normal urine output (unless contraindicated). | ||
13. Lower bed to safe position, remove gloves, and perform hand hygiene. | Lowering the bed helps prevent falls. Hand hygiene prevents the transmission of microorganisms from patient to health care provider. | ||
14. Document procedure according to agency policy. | Document time of catheter removal, condition of urethra, and any teaching related to post-catheter care and fluid intake. Document time, amount, and characteristics of first void after catheter removal. | ||
Data source: ATI, 2015d; BCIT, 2015b; Perry et al., 2014; VCH Professional Practice, 2014 |
If a patient is unable to void after six to eight hours of removing a urinary catheter, or has the sensation of not emptying the bladder, or is experiencing small voiding amounts with increased frequency, a bladder scan may be performed. A bladder scan can assess if excessive urine is being retained. Notify the health care provider if patient is unable to void within six to eight hours of removal of a urinary catheter. If a patient is found to have retained urine in the bladder and is unable to void, an intermittent/straight catheterization should be performed (Perry et al., 2014).
Critical Thinking Exercises
A tracheostoma is an artificial opening made in the trachea just below the larynx. A tracheostomy tube is a tube that is inserted through the opening, or stoma, to create an artificial airway. Patients who need long-term airway support (long-term patients who are intubated) or who have a need to bypass the upper airway may receive a tracheostomy. A tracheostomy (see Figure 10.1) can be very traumatic for a patient, and many find it difficult to adjust to having one.
The tracheostomy may be permanent or temporary. It is created surgically through the trachea (upper airway remains intact), larynx (upper airway is not patent), or cricothyroid (usually for temporary emergency access to airway). Tracheostomy tubes are inserted for airway maintenance, ventilation, removal of secretions, or as an alternate airway (e.g., following laryngectomy).
Tracheostomy tubes can be soft plastic, hard plastic, or, at times, metal. All tracheostomy devices are made up of an outer cannula, inner cannula, and an obturator used to insert the tube (see Figure 10.2). They come in different sizes and may have a cuff. A cuff tracheostomy produces a tight seal between the tube and the trachea. This seal prevents aspiration of oropharyngeal secretions and air leakages between the tube and the trachea. Tracheostomies are firmly tied and secured around the patient’s neck. The ties prevent accidental de-cannulation of the trachea. Sterile gauze and cleaning supplies are used daily to clean the trachea stoma and prevent infection to the site.
When a patient has a tracheostomy, air is no longer filtered and humidified as it is when passing through the upper airways. Most patients will have humidification and oxygen support. The following is a list of the special considerations of patients with a tracheostomy tube (BCIT, 2015c).
Early potential complications may include hemorrhage, pneumothorax, subcutaneous emphysema, cuff leak, tube dislodgement, and respiratory/cardiovascular arrest. Late potential complications may include airway obstruction, fistulae, infection, aspiration, and tracheal damage/erosion.
Emergency supplies at the bedside must include the following:
1. Suction equipment
2. Oxygen equipment with humidification
3. An emergency bag containing (see Figure 10.3):
The emergency bag must accompany patients when they are transported off the unit. Table 10.2 outlines methods to prevent possible complications that may arise from tracheostomies, and how to intervene if they do occur.
Complication | Prevention | Interventions |
Hemorrhage |
|
|
Stomal/pulmonary infection |
| Report potential signs of infection:
|
Tube occlusion |
| If tube occludes:
|
Aspiration |
| Report any signs of aspiration:
If patient vomits:
|
Accidental decannulation |
| If partial decannulation occurs (air movement is felt from tube):
If complete decanulation occurs, call for trained health care professional to reinsert tracheostomy tube. In the meantime:
|
Note: Do not hyperextend neck if patient has a known or suspected neck injury. | ||
Data source: BCIT, 2015c; Vancouver Coastal Health, 2012a |
The purpose of suctioning is to maintain a patent airway, to remove secretions from the trachea and bronchi, and to stimulate the cough reflex (Vancouver Coastal Health, 2006). Patients with tracheostomies often have more secretions than normal and will require suctioning to remove secretions from the airway to prevent airway obstruction. Tracheostomy patients should be assessed every two hours and as required to see if suctioning is required. Sterile suction equipment is used each time tracheal suctioning is performed. Secretions can be aspirated using a suction catheter connected to a suction source.
Tracheal suctioning is indicated with noisy respirations, decreased O2 sats, anxiousness, restlessness, increased respirations or work of breathing, change in skin colour, or wheezing or gurgling sounds. These are signs and symptoms of respiratory distress, and the patient should be suctioned immediately. Checklist 82 outlines the steps for tracheal suctioning.
Tracheostomy care is performed routinely and as required. Tracheostomy care is essential to avoid potential complications such as obstruction and infection. In addition to suctioning, tracheostomy care includes the following tasks:
If possible, these three tasks of tracheostomy care should be performed at the same time to minimize handling of the tracheal device. Collect all supplies at once and complete the procedure in the order listed above. However, there may be times when each task may be performed separately. Ongoing assessment is essential when caring for a patient with a tracheostomy.
Additional care includes:
The primary purpose of the inner cannula is to prevent tracheostomy tube obstruction. Many sources of obstruction can be prevented if the inner cannula is regularly cleaned and replaced. The inner cannula can be cleansed with half-strength hydrogen peroxide or sterile normal saline. Always check the manufacturer’s recommendations for tube cleaning. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Inner tube cleaning should be done as often as two or three times per day, depending on the type of equipment, the amount and thickness of secretions, and the patient’s ability to cough up the secretions.
Changing the inner cannula may encourage the patient to cough, bringing mucous out of the tracheostomy. For this reason, the inner cannula should be replaced prior to changing the tracheostomy dressing to prevent secretions from soiling the new dressing. If the inner cannula is disposable, no cleaning is required. Checklist 83 describes how to clean and replace an inner tracheal cannula.
The stoma should be cleaned and the dressing changed every 6 to 12 hours or as needed, and the peristomal skin should be inspected for skin breakdown, redness, irritation, ulceration, pain, infection, or dried secretions. Patients with copious amounts of secretions often require frequent dressing changes to prevent maceration of the tissue and skin breakdown. Cotton-tip applicators can be used to get under the tracheostomy device, where cleaning can be done using a semi-circular motion, inward to outward. Always use aseptic technique. Checklist 84 provides a safe method to clean the tracheal stoma and replace the sterile dressing.
Tracheal ties will become dirty and require replacing. Ties should be replaced as required, according to agency policy. Ideally, one person should hold the tracheostomy tube in place while the tracheostomy ties are replaced by another person. Alternatively, secure the new tracheostomy ties prior to removing the old tracheostomy ties to avoid accidental dislodgement of the tracheostomy tube if the patient coughs or the tracheostomy is accidentally bumped out. Once the new tracheostomy ties are on, only one finger should fit between the tracheostomy ties and the neck. Ensure twill ties are knotted using a square knot.
Checklist 85 lists the steps for replacing tracheostomy ties.
Critical Thinking Exercises
A chest tube, also known as a thoracic catheter, is a sterile tube with a number of drainage holes that is inserted into the pleural space. The pleural space is the space between the parietal and visceral pleura, and is also known as the pleural cavity. A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. Negative pressure is disrupted when air, or fluid and air, enters the pleural space and separates the visceral pleura from the parietal pleura, preventing the lung from collapsing and compressing at the end of exhalation. A small amount of fluid or air may be absorbed by the body without a chest tube. A large amount of fluid or air cannot be absorbed by the body and will require a drainage system (Bauman & Handley, 2011; Perry et al., 2014).
The chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained, and prevents air or fluid from entering the pleural space. The system is airtight to prevent the inflow of atmospheric pressure. Because the pleural cavity normally has negative pressure, which allows for lung expansion, any tube connected to it must be sealed so that air or liquid cannot enter the space where the tube is inserted (Bauman & Handley, 2011; Rajan, 2013).
The location of the chest tube depends on what is being drained from the pleural cavity. If air is in the pleural space, the chest tube will be inserted above the second intercostal space at the mid-clavical line. If there is fluid in the pleural space, the chest tube is inserted at the fourth to fifth intercostal space, at the mid-axillary line. A chest tube may also be inserted to drain the pericardial sac after open heart surgery, and may be placed directly under the sternum (Perry et al., 2014).
The following are some of the conditions that may require a chest tube drainage system (Bauman & Handley, 2011; Perry et al., 2014):
A chest tube drainage system must always be placed below the drainage site and secured in an upright position (attached to the floor or an IV pole, as in Figure 10.4) to prevent it from being knocked over.
A chest tube drainage system is a sterile, disposable system that consists of a compartment system that has a one-way valve, with one or multiple chambers, to remove air or fluid and prevent return of the air or fluid back into the patient (see Figures 10.5 and 10.6). The traditional chest drainage system typically has three chambers (Bauman & Handley, 2011; Rajan, 2013). Always review what type of system is used in your agency, and follow the agency’s and the manufacturer’s directions for setup, monitoring, and use. In general, a traditional chest tube drainage system will have these three chambers:
In addition to the three chambers, the drainage system has many safety features to ensure that high negative pressures can be monitored and relieved quickly. To review these safety features and additional information regarding the chambers of a closed chest tube drainage system, visit the Teleflex Medical Incorporated website.
When a patient has a closed chest tube drainage system, it is the health care provider’s responsibility to assess the patient and the equipment frequently to ensure the equipment is patent and working effectively. The health care provider should:
Checklist 86 reviews the management of a patient with a chest tube drainage system.
Table 10.3 provides a list of potential complications and interventions related to chest tube drainage systems.
Complications | Interventions | ||
Potential pneumothorax/respiratory distress | This is the primary concern for a patient with a chest tube drainage system.
| ||
Air leak | An air leak may occur from the chest tube insertion site or the drainage system. Do the following to test the system for the site of an air leak:
| ||
Accidental chest tube removal or chest tube falls out | A chest tube falling out is an emergency. Immediately apply pressure to chest tube insertion site and apply sterile gauze or place a sterile Jelonet gauze and dry dressing over insertion site and ensure tight seal. Apply dressing when patient exhales. If patient goes into respiratory distress, call a code. Notify primary health care provider to reinsert new chest tube drainage system. | ||
Accidental disconnection of the drainage system | A chest tube drainage system disconnecting from the chest tube inside the patient is an emergency. Immediately clamp the tube and place the end of chest tube in sterile water or NS. The two ends will need to be swabbed with alcohol and reconnected. | ||
Bleeding at the insertion site | Bleeding may occur after insertion of the chest tube. Apply pressure to site and monitor. | ||
Subcutaneous emphysema | Subcutaneous emphysema is painless tracking of air underneath the subcutaneous tissue. It may be seen in the chest wall, down limbs, around drain sites, or around the head or neck. When the skin is palpated, it feels similar to having tissue paper trapped beneath the skin. Monitor and report to primary health care provider. | ||
Drainage suddenly stops and respiratory distress increases | The chest tube may be clogged by a blood clot or by fluid in a dependent loop. Assess the drainage system and the patient and notify primary health care provider if required. | ||
Sudden increase in bright red drainage | This may indicate an active bleed. Monitor amount of drainage and vital signs, and notify the primary health care provider. | ||
Data source: ATI, 2015c; BCIT, 2015c; Perry et al., 2014; Teleflex Medical Incorporated, 2009 |
A Heimlich valve (see Figures 10.7 and 10.8) is a small, specially designed flutter valve that is portable and mobile, allowing the patient to ambulate with ease. It attaches to the chest tube at one end and a drainage bag at the other. The drainage bag allows air and fluid to escape but prevents their re-entering the pleural space. The valve can be worn under clothing. The valve functions in any position, never needs to be clamped, and can be hooked up to suction if required (Gogakos et al., 2015).
Critical Thinking Exercises
An ostomy is a surgically created opening from the urinary tract or intestines, where effluent (fecal matter, urine, or mucous) is rerouted to the outside of the body using an artificially created opening called a stoma. A stoma typically protrudes above the skin, is pink to red in colour, moist, and round, with no nerve sensations. Ostomy surgeries are performed when part of the bowel or urinary system is diseased and therefore removed. The output from the stoma (urine, feces, or mucous) is called effluent.
An ostomy is named according to the part of intestine used to construct it. A colostomy is the creation of a stoma from part of the colon (large bowel), where the intestine is brought through the abdominal wall and attached to the skin, diverting normal intestinal fecal matter through the stoma instead of the anus. An ileostomy is created from the ileum (small bowel), which is brought through the abdominal wall and used to create a stoma. A urostomy or ileal conduit is a stoma created using a piece of the intestine to divert urine to the outside of the body. The ureters are sewn to a piece of the intestine, brought through the abdominal wall, and sutured to create the stoma. These surgeries are performed on patients with diseases such as cancer of the bowel or bladder, inflammatory bowel diseases (such as colitis or Crohn’s), or perforation of the colon. Emergencies that may require an ostomy include diverticulitis, trauma, necrotic bowel, or radiation complications. An ostomy may be permanent or temporary, depending on the reason for the surgery. Other types of ostomies are called jejunostomy, double-barrel ostomy, and loop ostomy (Perry et al., 2014).
Individuals with colostomies, ileostomies, or urostomies have no control or sensation of frequency or output of the stoma. Patients with ostomies must wear a pouching system to collect the effluent from the stoma and protect the skin from irritation. The pouching system must be completely sealed to prevent leaking of the effluent and to protect the surrounding peristomal skin. The disposable pouching systems can be either a one-piece or a two-piece flexible system consisting of a plastic bag and a flange (skin barrier) that sit against the patient’s skin. The flange may be flat or convex. The ostomy pouch and flange come together to form one integrated, leakproof unit. The pouch has an open end to allow effluent to be drained, and may be closed using a plastic clip or Velcro strip. There are many different types of pouching systems to meet different needs. Step 2 in Checklist 87 shows ostomy supplies including a flange, an ostomy bag, and a one-piece system (Perry et al., 2104; United Ostomy Association of America, 2011).
The flange is cut to fit around the stoma without impinging on it. Ostomy pouching systems vary and are based on type of stoma, stoma characteristics, stoma location, patient abilities, skin folds, and patient preference. Depending on the type of pouching system, the system can last from four to seven days. The pouch must be changed if it is leaking, odour is present, there is excessive skin exposure, or the patient complains of itching or burning under the skin barrier. Patients with pouches can swim and take showers with the pouching system on. All patients are expected to participate in all aspects of the care of their ostomy; if they cannot, a caregiver may be taught to care for the ostomy (Perry et al., 2014).
Depending on the patient, a surgical procedure may be performed to create an internal pouch to collect feces or urine, which eliminates the need for an external pouch. The continent ileostomy is made from part of the ileum and is flushed a number of times each day to clean out the effluent. An ileoanal ostomy is a pouch created above the anal sphincter and is also created from a portion of the ileum. Two types of internal urinary diversions may be created from part of the intestine. The first is an orthotopic neobladder, where a bladder is created and placed in the body at a normal bladder position; over time, with continent training, the patient can learn to void normally. The second type is a continent urinary reservoir, where a pouch is created from part of the intestine, and a catheter is inserted a number of times during the day to remove the urine (Perry et al., 2014; United Ostomy Association of America, 2011).
Patients may have co-morbidities that affect their ability to manage their ostomy care. Conditions such as arthritis, vision changes, Parkinson’s disease, or post-stroke complications may hinder a patient’s coordination and function to manage the ostomy. In addition, the emotional burden of coping with an ostomy may be devastating for some patients and may affect their self-esteem, body image, quality of life, and ability to be intimate. It is common for ostomy patients to struggle with body image and an altered pattern of elimination. Ensure the patient has the appropriate referrals to the wound and ostomy nurse and social workers, as well as access to support groups or online support groups. As a health care provider, be very aware of non-verbal cues: take care not to show disgust at the ostomy or at odour that may be present when changing an appliance or pouching system (Perry et al., 2014).
Checklist 87 reviews the steps to change an ostomy pouching system (ostomy appliance).
A urostomy is similar to a fecal ostomy, but it is an artificial opening for the urinary system and the passing of urine to the outside of the abdominal wall through an artificially created hole called a stoma. A urostomy is created for the following reasons:
A urostomy patient has no voluntary control of urine, and a pouching system must be used and emptied regularly. Many patients empty their urostomy bag every two to four hours, or as often as they regularly used the bathroom prior to their surgery. Urostomy pouches (see Figure 10.9) have a drain at the end, and the pouch should be emptied when one-third full. The pouch may also be attached to a drainage bag for overnight drainage. Patients with a urostomy are more at risk for urinary tract infections (UTIs) and should be educated on the signs and symptoms of such infections (Perry et al., 2014).
Checklist 88 describes how to change a urostomy pouch.
Critical Thinking Exercises
When patients have tubes and attachments to aid in their recovery, health care providers are required to understand the type, purpose, precautions, complications, and interventions to ensure treatment is effective and to prevent patient harm. Each tube and attachment is unique, and the function of the tube, care of the patient, and safety precautions must be understood. This chapter reviewed many common types of tubes and attachments found in the acute and community setting, and reviewed the care and maintenance of nasogastric tubes, indwelling catheters, ostomies, urostomies, chest tube drainage systems, and tracheostomies.
Key Takeaways
ATI. (2015a). Inserting a nasogastic tube. Retrieved from ATI Nursing Education: Nasogastric intubation. http://www.atitesting.com/ati_next_gen/skillsmodules/content/nasogastric-intubation/viewing/insert-naso-tube.html?id=undefined
ATI. (2015b). Tracheostomy care. Retrieved from ATI Nursing Education: Airway management. Retrieved on Aug 24, 2015, from http://www.atitesting.com/ati_next_gen/skillsmodules/content/airway-management/viewing/trach_care.html
ATI. (2015c). Managing complications. Retrieved from ATI Nursing Education. Closed chest drainage. Retrieved on Aug 24, 2015, from http://www.atitesting.com/ati_next_gen/skillsmodules/content/closed-chest-drainage/equipment/managing.html
Bauman, M., & Handley, C. (2011). Chest tube care: The more you know, the easier it gets. Retrieved on Aug 26, 2015, from http://www.americannursetoday.com/assets/0/434/436/440/8172/8174/8176/8256/1d298438-82c6-439d-8b2e-77ffaf165fca.pdf
Berman, A., & Snyder S. J. (2016). Skills in clinical nursing (8th ed.). New Jersey, New York: Pearson.
British Columbia Institute of Technology (BCIT). (2015a). NURS 1186: Patient care for sonography. Vancouver: BCIT.
British Columbia Institute of Technology (BCIT). (2015b). NURS 2020: Clinical techniques. Vancouver: BCIT.
British Columbia Institute of Technology (BCIT). (2015c). NURS 3020: Clinical techniques. Vancouver: BCIT.
Centers for Disease Control and Prevention. (2015). Healthcare associated infections. Retrieved on Aug 26, 2015, from http://www.cdc.gov/HAI/ca_uti/uti.html
Durai, R., Hoque, H., & Davies, T. W. (2010). Managing a chest tube and drainage system. Retrieved on Aug 26, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/20152201
Gogakos, A. et al. (2015). Heimlich valve and pneumothorax. Retrieved on Aug 26, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381465/
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection Control Practice Advisory Committee. (2009). Guidelines for Prevention of Catheter Associated Urinary Tract Infections 2009. Center for Disease Control. Retrieved on Aug 26, 2015 from www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
Halm, M. A. (2007). To strip or not to strip? Physiological effects of chest tube manipulation. Retrieved on Aug 26, 2015, from http://ajcc.aacnjournals.org/content/16/6/609.full
Halm, M., & Krisko-Hagel, K. (2008). Instilling normal saline with suctioning: Beneficial technique or potentially harmful sacred cow? American journal of critical care, 17(5), 469-472.
Morris, L. L., Whitmer, A., & McIntosh, E. (2013). Tracheostomy care and complications in the intensive care unit. Retrieved on Aug 26, 2015, from http://www.aacn.org/wd/Cetests/media/C135.pdf
Ostomy Canada Society. (n.d.). Passing gas with an ostomy. Retrieved on Aug 24, 2015, from http://stolencolon.com/passing-gas-farting-ostomy/
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.
Rajan, C. S. (2013). Tube thoracostomy management. Retrieved on Aug 26, 2015, from http://emedicine.medscape.com/article/1503275-overview#a7
Registered Nurses Association of Ontario. (2009). Ostomy care and management. Toronto: Registered Nurses Association of Ontario.
Salmon, N., Lynch, S., & Muck, K. (2013). Chest tube management. Retrieved on Aug 26, 2015, from http://ajcc.aacnjournals.org/content/16/6/609.full
Teleflex Medical Incorporated. (2009). Chest drainage systems. Retrieved on Aug 26, 2015, from http://www.teleflex.com/en/usa/ucd/chest_drainage_systems.php
United Ostomy Association of America. (2011). Ileostomy guide. Retrieved on Aug 24, 2015, from http://www.ostomy.org/uploaded/files/ostomy_info/IleostomyGuide.pdf?direct=1
Vancouver Coastal Health. (2006). Tracheostomy and endotracheal tubes – suctioning. Vancouver: Vancouver Coastal Health.
Vancouver Coastal Health. (2012a). Tracheostomy: Care and management of a patient with a tracheostoma. Vancouver: Vancouver Coastal Health.
Vancouver Coastal Health. (2012b). Tracheostomy tubes: Dressing changes and inner cannula cleaning. Vancouver: Vancouver Coastal Health.
VCH Professional Practice. (2014). Indwelling urinary catheter: Procedure for insertion and removal (adult). Vancouver: Vancouver Coastal Health.
Glossary
The videos listed below and placed throughout this textbook are from Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition by Renée Anderson licensed under a Creative Commons Attribution 4.0 International License.
This page provides a record of edits and changes made to this book since its initial publication. Whenever edits or updates are made in the text, we provide a record and description of those changes here. If the change is minor, the version number increases by 0.01. If the edits involve substantial updates, the version number increases to the next full number
The files posted by this book always reflect the most recent version. If you find an error in this book, please fill out the Report an Open Textbook Error form.
Version | Date | Change | Details |
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1.00 | November 24, 2015 | Book published. | |
1.01 | May 16, 2018 | Several broken video links were removed and replaced with text suggesting the student watch a video or demonstration for the cited skill. | |
1.02 | November 16, 2018 | Made correction to section 7.4. | Replaced “NEVER give an IM injection in the dorsogluteal muscle. If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.” with “The dorsogluteal site should be avoided for intramuscular injections. If a needle hits the sciatic nerve, the patient may experience partial or permanent paralysis of the leg.” |
1.03 | December 14, 2018 | Made correction to section 6.4 and set table widths to 100%. | Replaced “The rectal route (see Figure 6.1) is not as reliable in absorption and distribution as oral and parenteral routes. The rectal route is, however, relatively safe because there is less potential for adverse effects (Perry et al., 2014).” with “Drugs administered PR have a faster action than via the oral route and a higher bio-availability – that is, the amount of effective drug that is available is greater as it has not been influenced by upper gastrointestinal tract digestive processes. Rectal absorption results in more of the drug reaching the systemic circulation with less alteration on route. As well as being a more effective route for delivering medication, rectal administration also reduces side-effects of some drugs, such as gastric irritation, nausea and vomiting” (Lowry, 2016, para 2).” Pages numbers in PDF will change. |
1.04 | June 5, 2019 | Updated the book’s theme | The styles of this book have been updated, which may affect the page numbers of the PDF and print copy. |
1.05 | October 9, 2020 | Added replacement videos to body and appendix of book. | Links to openly licensed videos created by TRU were added throughout this book. A summary of these videos are listed in the newly created Appendix 3. |
1.06 | April 16 and May 5, 2021 | Added remaining TRU videos body and appendix of book. | A summary of these videos are listed in the newly created Appendix 3. |
1.07 | May 20, 2021 | Updated metadata and front/back matter. Updated theme and styles. |
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1.08 | October 15, 2021 | Error correction. | Corrected mislabeling of dorsiflexion and plantarflexion images in 2.5 Head-to-Toe Assessment and 2.7 Focused Assessments. |