Holistic Skills Lab

*Med admin and another skill

*20 minutes

*Italicized - tested skills

5 Point Introduction:

  1. Knock on door

  2. Introduce yourself

    1. “Hi, my name is Emma, I will be your student nurse today”

  3. Hand hygiene and PPE

  4. Identify patient

    1. Name and DOB

    2. Patients MAR, compare with arm band

  5. Provide privacy

    1. Close door, curtain

  6. Explain procedure

    1. Verify allergies

    2. Ask for allergies (especially latex and iodine for catheters)

PPE

1-3 Using PPE

  1. Check MR and plan of care for type of precautions

  2. Perform hand hygiene

  3. Put on gown, mask, eyewear, and gloves

    1. Put on gown and tie securely at neck and then waist

    2. Put on mask/respirator over mouth, nose, and chin

      1. Secure ties at middle of head and neck

      2. Fit mask snug to face and below chin

      3. Fit flexible band to nose bridge

      4. Respiratory - fit check

        1. Inhale: collapse, exhale: air should not leak out

    3. Put on goggles over eyes and adjust fit (can use a face shield instead)

    4. Put on gloves (cover wrist of the gown)

  4. Continue with procedure

1-3 Removing PPE

*Remove PPE (except respirator) before existing patient room

*Remove respirator after leaving patient’s room and closing door

*Immediately perform hand hygiene if contaminated at any point

  1. Gown and gloves

    1. Grasp the gown in the front and pull away from body, breaking ties

    2. Fold/roll gown inside out into a ball

    3. Peel off gloves at the same time

    4. Discard in waste container

  2. Goggle/face shield

    1. Grab headband or earpieces and remove from back

    2. Lift up and away from face

    3. Discard in waste/reprocessing container

  3. Mask/respirator

    1. Grasp bottom ties of mask/respirator than top ties

    2. Lift away from face and remove

    3. Discard in waste container/save for future use

  4. Perform hand hygiene!

Sterile Field

Sterile Technique

  • UNSTERILE:

    • 1” border around sterile field

    • Edges of containers

    • Skin

  • Moisture-proof barrier must be used beneath sterile objects (shiny side)

  • If you must sneeze/cough, step away from field

  • Sterile procedures = quick

  • NEVER:

    • Let sterile touch unsterile

    • Unsterile objects in sterile field

    • Cross sterile field with unsterile objects

    • Turn back on sterile field

    • Drop sterile hands/sterile objects below waist

*IDENTIFY any breaks in sterility

1-4 Preparing a Sterile Field Using a Packaged Sterile Drape

  1. 5 point introduction

  2. Select a work area that is waist level and higher

  3. Check that sterile drape is dry and unopened (note expiration date - valid)

  4. Open outer covering of drape

  5. Remove sterile drape by lifting at corners

  6. Hold away from body

  7. Position the drape on the work surface with moisture-proof side down (shiny or blue side)

    1. Avoid touching any other surface or object with the drape

    2. If any portion hangs off the work surface = contaminated

  8. Place additional sterile items on field (1-6)

  9. Remove PPE, perform hand hygiene

  10. Continue with procedure

1-5 Preparing a Sterile Field Using a Commercially Prepared Sterile Kit or Tray

  1. 5 point introduction

  2. Select a work area that is waist level and higher

  3. Check that packaged kit is dry and unopened (note expiration date - valid)

  4. Open outer covering of package and remove kit/tray

  5. Place at center of work surface (topmost flap positioned on the far side of the package), discard outside cover

  6. Away, side, side, toward:

    1. Only touch 1 inch border

    2. Stand away from the work space when moving drape towards you

    3. Grab the wrapper on the underside and position the wrapper so that all edges are on the work surface

  7. The outer wrapper of the package is now a sterile field with packaged supplies in the center

  1. Place additional sterile items on field as needed (1-6)

  2. Continue with procedure

1-6 Adding Sterile Items to a Sterile Field

  1. 5 point introduction

  2. Check that the sterile, packaged drape and supplies are dry and unopened and note expiration date (note expiration date - valid)

  3. Choose a work area that is waist level

  4. Prepare a sterile field (1-4, 1-5)

  5. Add sterile item

  6. Continue with procedure

To Add a Facility-Wrapped and Sterilized Item

  1. Hold the item in the dominant hand, with top flap opening away from body

  2. With the other hand, reach around the package and unfold the top flap and both sides

  3. With a secure hold on the item with the dominant hand, grab the remaining flap of the wrapper closest to the body (don’t touch inner surface)

  4. Pull the flap back towards the wrist, so the wrapper should cover hand and wrist

  5. Grab all corners of the wrapper together with the nondominant hand and pull back toward wrist, covering hand and wrist, hold in place

  6. Hold the item above the surface of the sterile field and drop (avoid touching the surface or other items or dropping items onto 1-inch border)

To Add a Commercially Wrapped and Sterilized Item

  1. Hold package in one hand

  2. Pull back top cover with the other hand (or peel the edges apart using both hands)

  3. After top cover/edges are partially separated, hold the item above the surface of the sterile field, continue opening package and drop (avoid touching the surface or other items or dropping items onto 1-inch border)

  4. Discard wrapper

To Add a Sterile Solution

  1. Obtain solution and check expiration date

  2. Open solution according to directions

  3. Place cap on table away from the field with edges up

  4. Hold bottle outside the edge of the sterile field with the label side facing the palm of your hand and prepare to pour from a height of 4-6 inches (do not touch the tip of the bottle to the sterile container of field)

  5. Pour required amount of solution into sterile container (already added to sterile field and positioned at side of sterile field or onto dressings, avoid splashing)

  6. Touch the outside of the lid when recapping

  7. Label solution with date and time of opening

1-7 Putting on Sterile Gloves and Removing Soiled Gloves

  1. 5 point introduction (check for latex allergy)

  2. Place package on surface at waist level

  3. Check that sterile glove package is dry and unopened (note expiration date - valid)

  4. Open outside wrapper by peeling the top layer back

  5. Remove inner package, handling only the outside of it

  6. Place the inner package on work surface with the side labeled “cuff end” closet to body

  7. Open the inner package

    1. Fold open the top flap, then bottom, then sides

    2. DO NOT touch the inner surface of the package or the gloves

  8. With the nondominant hand, pinch the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove

  9. Keeping hand above waist, lift and hold the glove up and off the inner package with fingers down

    1. DO NOT let it touch any unsterile object

  10. Insert dominant hand palm up into glove and pull glove on, leave the cuff folded until the opposite hand is gloved

  11. Hold the thumb of the gloved hand outward

  12. Place fingers of the gloved hand into the cuff of the remaining glove

  13. Lift it from the wrapper, DO NOT touch anything with gloves or hands

  14. Insert nondominant hand into glove, pull glove on, DO NOT let skin touch any of the outer surfaces of the gloves

  15. Slide the fingers of one hand under the cuff of the other and fully extend the cuff down the arm, touching only the sterile outside of the glove, repeat for other hand

  16. Adjust gloves, touching only sterile areas with other sterile areas

  17. Continue with procedure

Removing Soiled Gloves

  1. *If hands are contaminated during PPE removal, immediately perform hand hygiene

  2. Grab the palm area of one gloved hand with the opposite gloved hand

  3. Remove it by pulling it off, inverting it

  4. Hold removed glove in remaining gloved hand

  5. Slide fingers of the ungloved hand between the remaining glove and the wrist

  6. Remove it by pulling second glove over the first glove, inverting it, and securing the first glove inside the second

  7. Discard gloves in container

  8. Remove any other PPE

  9. Perform hand hygiene

Catheters

12-7 Foley (Indwelling) Catheterizing the Urinary Bladder of a Patient

  1. Review pt record

  2. Gather equipment

    1. Foley kit, sterile gloves, catheter holder

  3. 5 point intro

  4. Equipment over bed table (working ht)

  5. Trash can

  6. Raise bed, stand on pt right side, side rail down

  7. Remove linens and gown

  8. Position pt

    1. F- knees flexed, feet apart, and legs to the side

    2. M - thighs slightly apart and legs straight

  1. Clean area (state)

  2. Remove gloves, wash hands

  3. New clean gloves

  4. Open cath tray between legs steriley

    1. Away, side, side, towards

  5. Blue drape

    1. Shiny side down

    2. Hip to hip

  6. Remove gloves, hand hygiene

  7. Sterile gloves (intact, expired?) - hand hygiene before putting on

  8. Drape with fenestrated drape

    1. Shiny side down

    2. Hip to hip

  9. Open supplies

    1. Remove cap from saline, attach to the balloon inflation port

    2. Open antiseptic swabs

    3. Open and put lubricant in the tray

  10. Remove cover on the catheter and lubricate

  11. Grab genitalia and clean

    1. Top to bottom

    2. Discard each swab after one stroke

    3. F - side, side, middle

    4. M - top to bottom and around

  1. Ask pt to breathe deeply and rotate catheter if met with resistance

  2. With dominant hand, hold catheter and insert into urethra until there is urine

    1. F - 2-3 inches

    2. M- 7-10 inches

  3. Once urine appears, move cath 2 more inches (do not force)

  4. Anchor cath securely

  5. Inflate balloon

    1. Inject all sterile water

    2. Remove syringe from port (while holding down on plunger)

  6. Pull on catheter to feel resistance

  7. Secure urine drainage setup to bed frame (make sure tubing is not kinked and side rails do not interfere)

  8. Secure the catheter tubing to the patient’s inner thigh with a catheter-securing device (allow for some slack)

  9. Remove equipment and dispose

  10. Clean area (state)

  11. Remove gloves, hand hygiene

  12. Position

  13. Cover PT

  14. Place bed in the lowest position, side rail up

  15. Hand hygiene and gloves

  16. Obtain urine specimen

  17. Remove gloves, hand hygiene

  18. Remind patient of call bell and ask if they need anything before you leave

12-9 Removing an Indwelling Urinary Catheter

  1. Review PT health record

  2. Gather equipment

  3. 5 point introduction

  4. Raise bed, stand on pt right side, side rail down

  5. Remove linens and gown

  6. Position patient as for cath insertion

  7. Drape patient

  8. Remove device used to secure catheter

  9. Insert syringe into balloon inflation port (volume of fluid in syringe = volume inserted)

  10. Deflate balloon

  11. Caution patients that there may be discomfort

    1. Ask patient to take slow deep breaths

  12. Remove catheter

  13. Place it on waterproof pad and wrap it in pad

  14. Clean area (state)

  15. Remove equipment and dispose

  16. Position

  17. Cover patient

  18. Place bed in lowest position, side rail up

  19. Hand hygiene, gloves

  20. Note characteristics and amount of urine in the drainage bag

  21. Remove gloves, hand hygiene

  22. Remind patient of call bell and ask if they need anything before you leave

Straight Catheter:

  1. Gather equipment

    1. Straight catheter kit, sterile gloves

  2. 5 point introduction

  3. Raise bed, stand on pt right side, side rail down

  4. Adjust over bed table (working ht)

  5. Trash can

  6. Remove gown and linens

  7. Position pt

    1. F - legs apart and bent

    2. M - legs apart and straight

  1. Clean area (state)

  2. Remove gloves, hand hygiene

  3. Open sterile kit (away, side, side, towards) in between patients legs

    1. Need to reposition - hip to hip

  4. Drape with blue drape

    1. Shiny side down

    2. Hip to hip

  5. Hand hygiene

  6. Sterile gloves (intact, expiration?) - hand hygiene before putting on

  7. Drape with fenestrated drape

    1. Hip to hip

    2. Shiny side down

  8. Open supplies (alcohol, lubricant) + lubricate cath

  9. Grab genitalia and clean

    1. Top to bottom

    2. Discard each swab after one stroke

    3. F - side, side, middle

    4. M - top to bottom and around

  10. Tell PT to take deep breath, rotate catheter if resistance is felt

  11. Insert catheter until urine shows, advance further (+ anchor)

    1. M - 7-10 inches, 2 inches advance

    2. F - 2-3 inches, 2 inches advance

  12. Let urine drain

  13. Remove catheter (tell patient to take deep breath)

  14. Remove equipment

  15. Take off sterile gloves

  16. Hand hygiene, gloves

  17. Position

  18. Cover patient

  19. Lower bed, place side rail up

  20. Remove gloves, hand hygiene

  21. Remind patient of call bell and ask if they need anything before you leave

Med Admin

*Used needle ALWAYS goes into SHARPS

*SCOOP UP method to CAP needles

*Keep needle capped when wasting!

3 Med Label Checks:

*DO NOT dispose of ampule in sharps until all checks done

*VOCALIZE checks

*Take a fourth med check before going to the bed space

  1. Pull (dispensing system)

    1. Read the MAR and select the proper med from the med supply system

  2. Prepare (before prep)

    1. After retrieving med from drawer, compare med label with MAR

  1. Prior to admin (beside after verifying patient identity OR before leaving med room OR both!)

    1. Recheck labels with MAR after identifying before administration OR recheck the label with MAR before taking the med to the patient

5 Rights: (after patient is ID)

  1. Right patient

  2. Right med

  3. Right dose

  4. Right route

  5. Right time

5-1 Administering Oral Medications

  1. Gather equipment

    1. MAR, water, medication + water cup, tape, pencil, work pad, medications (get out soon), little pink sheet

  2. Check each medication prescribed to health record + allergies

  3. Hand hygiene

  4. Read the MAR and read the label when selecting proper medication from the medication supply system (1st check)

  5. Read the label and compare the medication label with the MAR (2nd check)

    1. Check for expiration dates

    2. Perform calculations

  6. Prepare the required medications:

    1. *PO meds not being taken out, instead labeled (medication time, dose, and amount - ntda) and placed into a cup

  7. Read label and recheck the labels with the MAR before taking the medications to the pt (3rd check)

  8. Transport medications to pt’s bedside (keep in sight at all times)

  9. 5 point introduction

  10. State rights of patient (AFTER ID)

    1. Right patient

    2. Right med

    3. Right dose

    4. Right route

    5. Right time

  11. Complete necessary assessments

  12. Read label and recheck the label with the MAR before administering the medication (4th check)

  13. Position

  14. Administer medications

    1. Offer water

    2. Ask whether the patient prefer to take medications by hand or in a cup

  15. Position

  16. Remove PPE, hand hygiene

  17. Remind patient of call bell and ask if they need anything before you leave

  18. Evaluate patient’s response to the medication + document admin

5-3 Removing Medication From an Ampule

  1. Gather equipment

    1. Ampule, filtration needle, syringe, safety needle, alcohol wipes

Insulin Syringes:

  • Insulin syringe ONLY

    • Measured in units

    • Marked in units

    • Units aren’t converted for this med

1 mL Syringes:

  •  Small does under 1 mL

  • Calibrated in hundrenths of a mL

3-10 mL Syringes:

  • Meds >1 mL

  • Rounded to 1/10th

  1. Check each medication prescribed to health record + allergies

  2. Hand hygiene

  3. Read the MAR and read the label when selecting proper medication from the medication supply system (1st check)

  4. Read the label and compare the medication label with the MAR (2nd check)

    1. Check for expiration dates

    2. Perform calculations

      1. Heparin units → mL

  5. Tap the stem of the ampule

  6. Hand hygiene, gloves

  7. Scrub the neck of ampule using an alcohol pad, keep pad in place

  8. Breaking away from body, break off the top of the ampule

    1. DO NOT PUT IN SHARPS, only top in sharps

  9. Attach filter needle

  10. Remove the cap from the filter needle (hooty hoo)

  11. Withdraw entire medication

  12. Withdraw needle and tap the syringe

  13. Recap

  14. Check the amount of medication in the syringe with the medication dose and discard any surplus

  15. Read label and recheck the labels with the MAR before taking the medications to the patient (3rd check)

  16. Label syringe with medication time, dose, and amount (ntda)

  17. Remove filter needle

    1. DISCARD IN SHARPS

  18. Attach appropriate admin device to syringe (sq or IM)

  19. Remove gloves, hand hygiene

  20. Administration in pt’s room, based on prescribed route

5-4 Removing Medication From a Vial

  1. Gather equipment

    1. Vial, 1 mL syringe or insulin syringe, alcohol swaps, tape, pencil, work pad

Insulin Syringes:

  • Insulin syringe ONLY

    • Measured in units

    • Marked in units

    • Units aren’t converted for this med

1 mL Syringes:

  •  Small does under 1 mL

  • Calibrated in hundrenths of a mL

3-10 mL Syringes:

  • Meds >1 mL

  • Rounded to 1/10th

  1. Check each medication prescribed to health record + allergies

  1. Hand hygiene

  2. Read the MAR and read the label when selecting proper medication from the medication supply system (1st check)

  3. Read the label and compare the medication label with the MAR (2nd check)

    1. Check for expiration dates

    2. Perform calculations

      1. Insulin = no med math

      2. Heparin units → mL

  4. Remove cap on vial

  5. Scrub the top with antimicrobial swab and allow to dry

    1. 30 seconds

  6. Remove cap from needle (hooty hoo)

  7. Draw back an amount of air into the syringe = to the dose of medication to be withdrawn

  8. Pierce the vial at the center with the needle

  9. Inject air

  10. Invert vial

  11. Withdraw the medication

  12. Remove needle

  13. Tap syringe to remove air

  14. Recap

  15. Check the amount of medication in the syringe with the medication dose and discard any surplus over trash can

  16. Read label and recheck the labels with the MAR before taking the medications to the patient (3rd check)

  17. Label syringe with medication name, dose, and amount (ntad)

  18. Perform hand hygiene

  19. Administration, based on prescribed route

5-7 Administering a Subcutaneous Injection

  1. Gather equipment

    1. 5/8 inch needle, 23-25 gauge, 1 mL syringe (MAX), alcohol swaps, injection pad, gauze, vial/ampule, little pink tray

    2. Insulin syringe

  1. Transport medications to the patients bedside, keep the medications in sight at all times

  2. 5 point introduction

    1. After ID:

      1. Right patient

      2. Right med

      3. Right dose

      4. Right route

      5. Right time

  3. Complete necessary assessments

  4. Read label and recheck the labels with the MAR before administering the medications (4th check)

  5. Hand hygiene, gloves

  6. Select administration site

    1. State position!!!

    2. If not given one - just pick one

Ventrogluteal - thumb on groin, palm on greater trochanter of femur, pointer finger on anterior superior iliac spine (ASIS), middle finger on posterior iliac crest (PIC)

  • ASIS PIC

  • 1-1.5 inch needle

  • 22-25 gauge

  • 1-5 mL volume

Vastus Lateralis - divide femur into thirds, inject into outer middle third

  • 5/8 - 1.5 in needle

  • 22-25 gauge

  • 1-5 mL volume

Deltoid - palpate lower edge of acromian process, forma triangle at the midpoint in line with the axilla, inject into the middle of the triangle

  • 1-1.5 in needle

  • 22-25 gauge

  • 0.5-2 mL volume

  1. Position

  2. Cleanse with antimicrobial swab (30 secs)

    1. Use firm circular motion while moving outward from the injection site

    2. Dry (30 secs)

  3. Remove needle cap (hooty hoo)

  4. Hold syringe

  5. Pinch skin

  6. Inject needle at a 45 degree angle

  7. Release skin

  8. Inject medication

  9. Withdraw needle

  10. Engage safety or needle guard

    1. Put in SHARPS!    

  11. Blood/clear fluid appears = use gauze square to apply pressure

  12. Remove gloves, hand hygiene, gloves

  13. Position

  14. Remove PPE, hand hygiene

  15. Remind patient of call bell and ask if they need anything before you leave

  16. Evaluate patient’s response to the medication + document admin

5-8 Administering an Intramuscular Injection

  1. Gather equipment

    1. 1.5 inch needle, alcohol swaps, injection pad, gauze, vial/ampule, little pink tray

  2. Transport medications to the patients bedside, keep the medications in sight at all times

  3. 5 point introduction:

    1. After ID:

      1. Right patient

      2. Right med

      3. Right dose

      4. Right route

      5. Right time

  1. Complete necessary assessments

  2. Read label and recheck the labels with the MAR before administering the medications (4th check)

  3. Select administration site

  4. Position + expose PT if needed

  5. Identify the appropriate landmarks and site boundaries for the site chosen

    1. State position!!!

    2. If not given one - just pick one

Ventrogluteal - thumb on groin, palm on greater trochanter of femur, pointer finger on anterior superior iliac spine (ASIS), middle finger on posterior iliac crest (PIC)

  • ASIS PIC

  • 1-1.5 inch needle

  • 22-25 gauge

  • 1-5 mL volume

Vastus Lateralis - divide femur into thirds, inject into outer middle third

  • 5/8 - 1.5 in needle

  • 22-25 gauge

  • 1-5 mL volume

Deltoid - palpate lower edge of acromian process, form a triangle at the midpoint in line with the axilla, inject into the middle of the triangle

  • 1-1.5 in needle

  • 22-25 gauge

  • 0.5-2 mL volume

  1. Cleanse with antimicrobial swab (30 secs)

    1. Use firm circular motion while moving outward from the injection site

    2. Allow area to dry (30 secs)

  2. Remove needle cap (hooty hoo)

  3. Hold syringe

  4. Pull skin taunt

  5. Dart the needle into the tissue (90 degrees)

  6. Release skin

  7. Insert solution

  8. Withdraw needle

  9. Engage safety or needle guard

    1. Place needle in SHARPS!

  10. Use gauze square to apply pressure to the site

  11. Remove gloves, hand hygiene, glove

  12. Position

  13. Remove PPE, hand hygiene

  14. Remind patient of call bell and ask if they need anything before you leave

  15. Evaluate patient’s response to the medication + document admin

    1. Assess site 2-4 hours after administration

Wound Care

Wound Assessments

  • REEDA

    • Redness

    • Edema

    • Ecchymosis (bruise)

    • Discharge, drainage

    • Approximation (how neat it looks)

8-2 Cleaning a Wound and Applying a Dressing

  1. Review pt health record

  2. Gather supplies

    1. Gloves - clean and sterile

    2. Sterile bowl

    3. Sterile instruments

    4. Saline, sterile water

    5. Gauze

      1. Non-woven drain sponges (trach or split)

      2. Abdominal pad (blue to the sky)

      3. Disposable pad

    6. Tape

    7. Hand sanitizer

    8. MAR

    9. Waterproof pad

  3. 5 point introduction

    1. Pain medication before wound care dressing change

      1. Proper medication

      2. Time for it to take effect

  4. Assemble equipment on overbed table (working ht)

  5. Trash can

  6. Raise bed, side rail down, stand on pt right side

  7. Position

    1. Move leg internally

  8. Waterproof pad under the wound site

  9. Hand hygiene, gloves

  10. Loosen the tape

  11. Lift dressing

  12. Remove soiled dressings

  13. Place in biohazard

  14. Remove gloves, hand hygiene, gloves

  15. Inspect wound (REEDA)

    1. Pain?

  16. Prepare a sterile work area and open the needed supplies

    1. Place basin closest to patient bed by scooping hand underneath drape and pushing basin

    2. Get tape ready (5 pieces) - label dressing with date and time (dt)

  17. Remove gloves, hand hygiene

  18. Open sterile cleaning solution, pour into basin

  19. Sterile gloves (intact? expired?)

  20. Moisten gauze for cleaning

  21. Clean the skin surrounding the wound

    1. Clean from top to bottom

      1. Middle, medial, lateral

    2. Use a new gauze for each wipe, placing the used gauze in the waste receptacle

  1. Secondary dressing

    1. Abdominal pad - blue to the sky

  2. Remove gloves, hand hygiene, gloves

  1. Remove all equipment

  2. Position

    1. Side rails up, bed in lowest position

  3. Remove PPE, hand hygiene

  4. Remind patient of call bell and ask if they need anything before you leave

  5. Check all wound dressing at least every shift (more frequent checks if wound is complex)

8-6 Caring for a Jackson-Pratt Drain

  1. Review pt health record

  2. Gather supplies

    1. Gloves - clean and sterile

    2. Sterile bowl

    3. Sterile instruments

    4. Saline, sterile water

    5. Gauze

      1. Non-woven drain sponges (trach or split)

      2. Abdominal pad (blue to the sky)

      3. Disposable pad

    6. Tape

    7. Hand sanitizer

    8. MAR

    9. JP drain

    10. Q-tips

    11. Waterproof pad

  3. 5 point introduction

    1. Ask patient if they need pain medication

      1. Administer med

      2. Allow enough time for it to take effect

  4. Equipment on overbed table (working ht)

  5. Trash can

  6. Raise bed, side rail down, stand on patients right side

  7. Position

Emptying Drainage

  1. Hand hygiene, gloves

  2. Place graduated collection container under the drain outlet

  3. Pull off the cap

  4. Empty chambers content

  5. Fully compress the chamber, and replace cap

  6. Carefully measure and record the character, color, and amount of the drainage

  7. Discrad drainage

  8. Remove gloves, hand hygiene

Cleaning the Drain Site

  1. Hand hygiene, gloves

  2. Loosen the tape

  3. Lift dressing

  4. Remove soiled dressings

  5. Place in biohazard

  6. Remove your gloves, hand hygiene

  7. Inspect drain and wound site (REEDA)

    1. Pain?

  8. Using sterile technique, prepare a sterile work area and open the needed supplies

    1. Place basin closest to patient bed by scooping hand underneath drape and pushing basin

    2. Get tape ready - label dressing (date and time - dt)

  9. Remove gloves, hand hygiene

  10. Open sterile cleaning solution

    1. Pour it into the basin, add the gauze supplies

  11. Sterile gloves (intact? expiration?) - hand hygiene before putting on

  1. Cleanse the drain site with cleaning solution

    1. Middle of suture, medial of suture, lateral of suture, above JP drain, below JP drain (moving medial to lateral)

    2. Use each gauze sponge only once

    3. Discard and use new gauze for additional cleaning

  1. Place a pre-split drain sponge under the drain (use q-tips here)

  2. Apply gauze pads or other cover dressing over drain

  3. Secure dressing with tape

  4. Remove gloves, hand hygiene, gloves

  5. Remove all equipment

  6. Position

    1. Side rails up, bed in lowest position

  7. Remove PPE, hand hygiene

  8. Remind patient of call bell and ask if they need anything before you leave

  9. Check drain every 4 hours

    1. Empty and reengage suction which device is 25-50% full

    2. Check all wound dressing at least every shift (more frequent for complex wounds or saturated dressings)

13-6 Emptying and Changing an Ostomy Appliance

  1. Gather supplies

    1. Waterproof pad, clean gloves, basin, drape, warm water, ostomy bag, gauze, scissors, toilet tissue

  2. 5 point introduction

  3. Assemble equipment on over bed table

  4. Raise bed, side rail down

  5. Remove linens and gown

  6. Waterproof pad under patient at stoma site

Emptying an Appliance

  1. Gloves

  2. Remove clamp and fold the end of the appliance or pouch upward like a cuff

  3. Empty contents

  4. Wipe lower 2 inches of the appliance or pouch with toilet tissue/paper towel

  5. Uncuff the edge of the appliance or pouch any apply a clip/clamp or secure the velcro closure

  6. Remove gloves, hand hygiene

  7. Position

  8. If appliance is not to be changed, place the bed in the lowest position, remove PPE, and hand hygiene

Changing an Appliance

  1. Place a disposable pad on the work surface

  2. Set up the washbasin with warm water and the rest of the supplies

  3. Trash can

  4. Perform hand hygiene, gloves

  5. Place a waterproof pad under the patient at the stoma site

  6. Empty the appliance

  7. Hand hygiene, gloves

  8. Use two hands to gently remove the appliance (top → bottom)

  9. Remove the appliance from the skin

  10. Place in the trash bag

  11. Use toilet tissue to remove any excess stool from the stoma

  12. Cover with a gauze pad

  13. Clean the skin around the stoma

  14. Gently pat the area dry

    1. Make sure the skin around the stoma is thoroughly dry

  15. Assess the stoma and the condition of the surrounding skin (REEDA)

  16. Measure the stoma opening, using the measurement guide

  17. Trace the same-sized opening on the back center of the appliance

  18. Cut the opening larger than the stoma size

  19. Using a finger, gently smooth the wafer edges after cutting

  20. Remove the paper backing from the appliance

  21. Quickly remove the gauze squares and place the appliance over the stoma

  22. Press it onto the skin while smoothing over the surface

  23. Apply pressure to the appliance for approximately 30 seconds

  24. Close the bottom of the appliance or pouch by folding the end upward and using the clamp or clip that comes with the product, or secure the Velcro closure

  25. Remind patient of call bell and ask if they need anything before you leave