Procedure Manual, Lecture notes of Nursing

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Pensacola Christian College

Department of Nursing

Procedure

Manual

NU Procedure Manual

• Blood Glucose Monitoring Table of Contents
• Blood Transfusions...............................
  • Blood Draw Central Line
  • Dressing Change.........................
  • Flushing
  • Assessment Chest Tube
  • Dressing Change.......................
  • Routine Assessment.................. Documentation Guidelines
  • Mental Health Assessment
  • Critical Care
  • Postpartum
  • Newborn
  • Running Notes
  • Sample Abnormals
• Dopplering Pulses...............................
• Drain Removal
• Dressing Change.................................
• Enema
• Eye Drop Administration
  • Insertion Gastric/Enteric Tubes
  • Checking Placement
  • Checking Residual
  • Flushing
  • Medication Administration.......
  • Removal....................................
• Handwashing
• Hygiene
  • Intradermal Injections
  • Intramuscular
  • Subcutaneous
  • Locating Sites
  • Medication Reconstitution........
• Insulin Pen
  • Insertion/Care Intravenous Therapy
  • Medication Administration.......
    • Isolation Procedure
    • Medication Administration
    • Metered Dose Inhalers
    • Moving and Transferring Patient
    • Needlestick Protocol
      • Emptying/Changing Pouch Ostomy Care
      • Irrigating
    • Oxygen Therapy
    • Patient-Controlled Analgesia
      • Routine Assessment Physical Assessment
      • Respiratory Specific..................
      • Cardiovascular Specific
      • Neurovascular Specific
      • Neurological Specific
      • Critical Care
      • Mental Health
      • Newborn
      • Postpartum
      • Vest Restraints
      • Limb........................................
      • Mitt/Elbow/Belt
    • Staple/Suture Removal
    • Suctioning
    • T-Tube Care......................................
    • Tracheostomy Care
    • Urinary Catheterization
    • Urine Specimen Collection
    • Venipuncture (Blood Draw)
      • Temperature Vital Signs
      • Pulse........................................
      • Respirations/Pulse Ox.............
      • Blood Pressure
      • Pain
      • Normal Ranges
    • Wound Culture

9. Touch the blood to the edge of the test strip until the collection area is full.
10. Hold a clean cotton ball to the puncture site until the bleeding has stopped. Apply a bandage to the heel of an infant.
11. An hourglass should appear on the screen of the machine while it is calculating the glucose level. Wait for the reading.
12. Take any immediate action necessary based on the glucose level.
13. Discard the supplies that were used. Lancets must be discarded in a sharps container.
14. Remove gloves and wash hands.
15. Return the machine and test strips back to the appropriate place.
16. Document the glucose level and actions taken.

Sources Used: Bartelmo, Joanne, ed. 2003. Best Practices: A Guide to Excellence in Nursing Care. Springhouse, PA: Lippincott Williams & Wilkins.

Evans-Smith, Pamela. 2005. Taylor’s Clinical Nursing Skills: A Nursing Process Approach. Philadelphia: Lippincott Williams & Wilkins.

Perry, Anne, Patricia Potter, and Wendy Ostendorf. 2014. Clinical Nursing Skills and Techniques. 8th ed. St. Louis: Elsevier.

Sacred Heart Health System. 2003. “Accu-Check Blood Glucose Monitor.” Policies and Procedure. Policy no. PA10 (January). Sacred Heart Hospital, Pensacola, FL.

West Florida Hospital. 2006. “Accudata Glucose Test Station: Accucheck Inform for Glucose Monitoring.” Policies and Procedures. Book 1, Section 1, #4B (February). West Florida Hospital, Pensacola, FL.

Procedure Manual Blood Transfusions

Pensacola Christian College Department of Nursing

January 19, 2007 Approved: 2/23/ Revised: 10/21/

Supplies Needed: Saline Flushes Blood component Blood tubing set 250-500 mL bag of NS Alcohol swabs Clean gloves Biohazard bag IV pump VS equipment

Procedure:

1. Verify healthcare provider’s order for blood type, amount to be infused, date and time of infusion, and flow rate.
2. Verify that blood consent form is in chart and is signed (obtain from patient or family if not in chart).
3. Verify patient has a patent 18 or 20 gauge IV catheter by flushing the line with NS.
4. Verify that a blood bank ID bracelet is on patient’s arm.
5. Before picking up the blood from the blood bank, obtain patient’s vital signs. Call healthcare provider if temperature is elevated per facility protocol.
6. Obtain blood/blood product from the blood bank. The blood may be picked up by any designated facility employee or volunteer with the appropriate paperwork.
7. The color and appearance of the blood should be examined. If it has a brown color, contains clots, or is separated, it should be returned to the blood bank.
8. At the patient’s bedside: a) Have the patient state his full name and DOB. b) Two licensed personnel must verify and document that the following information on the patient’s ID bracelet, the blood bank ID bracelet, transfusion report form, and the blood component bag matches: i) Patient’s name ii) Patient’s medical record number iii) Donor number iv) Blood type and Rh v) Blood bank number (number and letter code) vi) Expiration date/time c) Teach the patient or family signs and symptoms of transfusion reaction.

Sources Used: Baptist Hospital. Policies and Procedures. Baptist Hospital, Pensacola, FL.

Sacred Heart Health System. Policies and Procedure. Sacred Heart Hospital, Pensacola, FL.

West Florida Hospital. Policies and Procedures. West Florida Hospital, Pensacola, FL.

10. Insert end of blood transfer device (or needle) into each blood specimen tube, filling each tube at least halfway.
11. Flush port with at least 20 mL NS, ensuring all blood is completely cleared from the line. Cleanse blood off port with alcohol swab. If ordered, reattach IV tubing and resume infusion.
12. Discard all syringes and blood transfer devices in sharps container.
13. Attach patient label to each specimen tube and write date, time, and initials. Place all blood collection tubes in small biohazard specimen bag(s) per facility policy.
14. Discard gloves and other used supplies in the trash. Return patient’s bed to lowest level. Wash hands.
15. Document blood collection, complete lab requisition, and send specimen tubes to the lab.

Sources Used: West Florida Hospital. 2012. “Central Venous Catherters and vascular Access Devices: Insertion, Care, and Use.” Policies and Procedures. (October). West Florida Hospital, Pensacola, FL.

Procedure Manual Central Line (Dressing Change)

Pensacola Christian College Department of Nursing

January 19, 2007 Approved: 3/9/ Revised: 10/ 21 /

Supplies Needed: Biopatch End Caps (one for each lumen) NS Flushes Stat-Lock (unless central line is sutured) Skin Prep Steri-Strips Sterile transparent dressing (gauze dressing may also be used) Chlorhexidine stick Masks (two if you are planning to have the patient wear one) Clean gloves Sterile gloves Tape *Some of this material may be pre-packaged in a sterile dressing kit

Procedure:

1. Gather all needed materials.
2. Check allergies to ensure the patient is not allergic to any materials used.
3. Identify patient. Wash your hands.
4. Explain the procedure to the patient and have the patient turn his head away from the central line site (or you may have the patient wear a mask instead).
5. Apply mask and clean gloves.
6. Carefully remove the dressing by peeling it off toward the insertion site. Remove all tape and steri-strips from around the insertion site.
7. Unclip Stat-Lock. Remove Biopatch and Stat-Lock and discard in trash can. (Do not remove sutures.)
8. Assess the insertion site and skin noting any odor, redness, edema, ecchymosis, and drainage. Note the markings on the central line to ensure that the line has not migrated further in or out.
9. Remove and discard gloves.
10. Open sterile dressing package by the edges being careful not to contaminate contents. If not part of kit, open Biopatch, Stat-Lock, skin prep, and steri-strips and drop onto sterile field.
11. Apply sterile gloves.

Procedure Manual Central Line (Flushing)

Pensacola Christian College Department of Nursing

January 19, 2007 Approval: 3/2/ Revised: 10/21/

Supplies Needed: 10 mL NS flushes Alcohol swabs Clean gloves

Procedure:

1. Routine flush a) Remove cap from syringe (keep cap sterile). Gently pull back on plunger of 10 mL NS flush to break suction. Expel all air from syringe and reapply cap. b) Apply clean gloves. c) Scrub the hub with alcohol swab for 15 seconds and allow to air dry. d) Attach the syringe. e) Unclamp the line you are flushing. f) Flush the line with 2 mL NS. Pull back to check for blood return. Flush the line with the remaining 8 mL NS. g) Holding positive pressure on the plunger of the syringe, re-clamp the line. h) Disconnect syringe from the port.

 If you meet resistance, gently pull back on the plunger and try flushing again. If unable to flush or obtain blood return, notify appropriate personnel.  If no infusion is running, flushing should be completed at least every 12 hours to keep the line open. If the central line has multiple lumens, you must flush each port.

2. Flushing for medication administration a) Follow the same procedure above with the following exception: i) 10 mL of normal saline will be administered prior to administering the medication and ii) 10 mL after administering the medication (flush saline at approximately the same rate as the medication for the first 2 mL). b) Lines should be flushed between each medication.
3. Flushing after infusing blood products or after drawing blood from the central line a) Follow the same procedure as number one with the following exception: b) Flush the line with 20 mL of normal saline rather than 10 mL.
4. Flushing a central line after hyperalimenation or TPN has been administered a) Follow the same procedure as number one with the following exception: b) Flush the line with 20 mL of normal saline rather than 10 mL.

You must use a 10 mL syringe as anything smaller will create pressure that may damage the central line.

Sources Used: Baptist Hospital. Policies and Procedures. Baptist Hospital, Pensacola, FL.

West Florida Hospital. Policies and Procedures. West Florida Hospital, Pensacola, FL.

 Continuous bubbling indicates an air leak in the system or around the CT insertion site. Report this to the HCP, and check for possible air entry sites.  Bubbling will not be seen with medialstinal CT because they are not in the pleural space.

5. Drainage: a) Assess collection chamber for amount of drainage at the beginning of each shift and hourly. b) Assess the color and clarity of the drainage in the tubing. c) Measure drainage output at the end of every shift by marking the collection chamber with the date, time, and amount of drainage. i) Drainage should not exceed more than 100 mL/hr in adults. ii) Drainage should not exceed more than 5 mL/kg/hr or 3 mL/kg/hr for 3 consecutive hours in children. iii) If drainage is excessive, the HCP should be notified immediately.

Never empty a chest tube collection system. The amount in the collection chamber should be a running total for the entire time the chest tube is in place. If the collection chamber becomes completely full, the entire system must be changed out.

6. Chest tube site and dressing: a) Apply clean gloves. b) Palpate area around chest tube site to determine if subcutaneous air (called crepitus or subcutaneous emphysema) is present. This will feel like bubbles in the subcutaneous tissue. c) Determine anatomical placement of chest tube. Document if tube is placed mid-axillary, mid-clavicular, or other location. Also determine the intercostal space (ICS) in which the tube is placed. This may require palpation of the chest tube dressing or looking at documentation of the insertion procedure. d) Chest tube dressings should be an occlusive dressing. A petroleum gauze is used only after the initial insertion. e) Have the patient turn, cough and deep breath every four hours and PRN.
7. A mneumonic to help you to remember what to assess and document: DR PD PADS a) D evice (type/brand name) b) R espiratory status c) P atency (tidaling) d) D rainage (color, amount) e) P lacement (anatomical location)

f) A ir leak (none, intermittent, or continuous) g) D ressing h) S uction

Emergency Procedures:  The following emergency equipment must always be kept at the bedside and transported with the patient (rubber-tipped Kelly clamps, petroleum gauze, and bottle NS).  If CT is dislodged, cover the insertion site with petroleum gauze.  If the CT becomes disconnected from the drainage device, temporarily clamp the CT with the CT clamp or rubber-tipped Kelly clamps. Place the end of the CT into bottle of NS, unclamp the tubing, and notify HCP.  Never clamp a CT without an order.

Procedure Manual Chest Tube (Dressing Change)

Pensacola Christian College Department of Nursing

January 18, 2007 Approval: 4/13/ Revised: 1/16/

Supplies Needed: Clean gloves Sterile gloves Petroleum gauze Sterile 4x4 gauze Sterile ABD pad Drain sponge Tape Normal saline Chlorahexadine swabs

Procedure:

1. Verify healthcare provider order.
2. Gather supplies.
3. ID patient and explain procedure.
4. Provide a clean working area on the over bed table: Raise the table to waist level. Place the trash can where supplies can easily be disposed.
5. Wash hands.
6. Arrange sterile packages on table in the order in which they will be used.
7. Raise the bed, lower the side rails.
8. Lift up gown to visualize chest tube dressing, minimally exposing the patient; allow yourself room to work.
9. Open sterile packages just before use without reaching over open packages, or contaminating gauze. Remember the outer edge of sterile packages (where the glue was) is considered contaminated.
10. Apply clean gloves; and carefully remove old dressing.
11. Observe site for odor, redness, edema, ecchymosis, drainage, and approximation of wound edges (OREEDA), and drainage for color, consistency, odor, amount, and location of drainage (CCOAL).
12. Remove old gloves and apply sterile gloves.

Procedure Manual Documentation Guidelines

Pensacola Christian College Department of Nursing

January 18, 2007 Approval: 4/27/ Revised: 05/17/

General Guidelines

1. Students are to write a daily narrative note for the patient(s) they had that day. The note is to be turned in at clinical.
2. Every note begins with the actual date and time the assessment or procedure was completed and ends with a signature.
3. The order of the note is in a general head-to-toe fashion, noting that peripheral extremity assessments of circulation (edema, pulses, and capillary refill) are included with the cardiovascular section.
4. Findings for all specific assessments are to be documented in the narrative note.
5. Items below in brackets are other word choices that may be used to describe a specific finding.
6. When abnormal assessments are identified, the nursing intervention must be documented along with the findings, and reassessments. (i.e. Rhonchi heard in upper anterior lobes; had patient cough, deep breath and use incentive spirometer. Reauscultation reveals clear upper lobes.)

Narrative Notes

1. Normal Head-to-Toe Assessment Note a) The head-to-toe assessment note must include the following categories  Neurological  Neurovascular  Respiratory  Cardiac

 Gastrointestinal  Genitourinary  Skin/Dressings  Equipment/Safety b) Sample note with normal findings 4/20/14 0735 A and O x 3. Follows commands, PERRLA, brisk, 4mm. (neurological) MAEW.(neurovascular)^ Upper and lower BBS clear to ausculation anterior and posterior, O 2 Sat 96% on room air, respirations even & unlabored at 18.(respiratory)^ AP, strong & regular, Tel #45 showing normal sinus rhythm; No edema in extremities, DP, PT, and radial pulses strong bilaterally, capillary refill less than 2 seconds x 4 extremities.(cardiac) Abdomen soft, nontender, nondistended; bowel sounds active. Stated normal BM this am.(gastrointestinal)^ Voiding adequate amount clear, yellow urine without difficulty.(genitourinary)^ No skin breakdown noted. Lt hip gauze dressing clean, dry and intact.(skin/dressings)^ IV reseal intact to LFA without redness, edema, drainage, or tenderness at site, dressing clean, dry and intact. Denies pain. SR  x 2, bed level , HOB 30 degrees, call light in reach. Contact isolation ongoing.(equipment/safety) ________ _________________________________________________________________ (^) N. Nurse, SN, PCC