NFDN – 2003 LAB 1 SKILLS (V1.

09)

DATE: _________________ STUDENT NAME: __________________

SKILL COMMENTS
Skill 47–3 Applying Dry and Moist Dressings
Dressing changes
(Simple and Complex)
1. Perform hand hygiene. Obtain information about size and
location of the wound.
- Position yourself
and your tray so 2. Assess the client’s level of comfort.
that you don’t have 3. Review orders for dressing change procedure.
to reach over the 4. Explain procedure to the client, and instruct the client not to
tray touch the wound area or sterile supplies.
- Open the tray use
5. Close curtains.
tweezers to move
stuff around, 6. Position the client comfortably, and drape with a bath
position garbage blanket to expose only the wound site.
bag so you don’t 7. Place a disposable bag within reach of the work area. Fold
have to reach over the top of bag to make a cuff.
wound or your tray 8. Put on a face mask and protective eyewear, if splashing
- Put on gloves and occurs.
remove the old
9. Put on clean, disposable gloves, and remove tape, bandage,
bandage, dispose or ties.
into garbage along
with gloves, put on 10. Remove tape: Pull parallel to skin toward dressing; remove
remaining adhesive from skin.
fresh gloves
- Assess wound, 11. With your gloved hand, carefully remove gauze dressings
look for signs of one layer at a time, taking care not to dislodge drains or
infection, odour or tubes.
redness, etc. A. If dressing sticks on a wet-to-dry dressing, do not
- Take gauze in moisten it; instead gently free the dressing, and alert the
forceps, dip gauze client of potential discomfort.
into the normal 12. Observe the character and amount of drainage on the
saline, hold the dressing and the appearance of wound.
gauze below your 13. Fold dressings with drainage contained inside, and remove
wrists at all times. gloves inside out. With small dressings, remove gloves
- Use other forceps inside out over the dressing. Dispose of gloves and soiled
to squeeze gauze dressings in disposable bag. Perform hand hygiene.
of excess saline 14. Open the sterile dressing tray or individually wrapped
- Wipe wound from sterile supplies. Place on the bedside table).
least contaminated
15. If ordered, cleanse or irrigate the wound:
to most
contaminated, a A. Pour the ordered solution into the sterile irrigation
drain is the most container.
contaminated B. Using a syringe, gently allow the solution to flow over
- Along the incision the wound.
line is considered C. Continue until the irrigation flow is clear.
the cleanest part
 of the wound D. Dry the surrounding skin.
- Use each gauze 16. Apply dressing.
only once, clean
along the edges of A. Dry dressing:
the incision, dry (1) Put on sterile gloves.
the wound and (2) Inspect the wound for appearance, drains, drainage,
then clean the and integrity.
drain, use one (3) Cleanse the wound with solution:
gauze for each
circle around the (a) Clean from the least contaminated area to the
most contaminated area.
drain.
- Apply drain (4) Dry the area.
dressing using (5) Apply sterile, dry dressing to cover the wound.
forceps, secure (6) Apply topper dressing if indicated.
with tape
B. Moist dressing:
(1) Put on clean gloves.
(2) Remove and discard old dressings.
(3) Assess the surrounding skin. Discard gloves.
(4) Put on sterile gloves.
(5) Cleanse the wound base with normal saline or
commercially prepared wound cleanser. Assess the
wound base.
(6) Moisten gauze with the prescribed solution. Gently
wring out excess solution. Unfold gauze.
(7) Apply gauze as a single layer directly onto the
wound surface. If the wound is deep, gently pack
dressing into the wound base by hand or with
forceps until all wound surfaces are in contact with
the gauze. If tunnelling is present, use a cotton-
tipped applicator to place gauze into the tunnelled
area. Be sure gauze does not touch the surrounding
skin.
(8) Cover with sterile dry gauze and topper dressing.
17. Secure dressing:
A. Tape: Apply nonallergenic tape to secure dressing in
place.

B. Montgomery ties.
(1) Expose adhesive surface of tape on the end of each
tie.
(2) Place ties on opposite sides of the dressing.
(3) Place adhesive directly on the skin, or use a skin
barrier.
C. For dressings on an extremity, secure dressing with
rolled gauze or an elastic net.
18. Remove gloves, and dispose of them in the bag. Remove
 any mask or eyewear.
19. Dispose of supplies, and perform hand hygiene.
20. Assist the client to a comfortable position.

- Shorten drain: cleanse around drain site from outside

Care and removal of in, using one swab per round
surgical drains - grab drain with forceps, ask client to take slow deep
Penrose/JP & Hemovac breaths, gently pull drain out as client exhales, insert
safety pin closer to the where drain exists the skin
- cut drain between the two safety pins with sterile
scissors, cleans around drain
- apply dressing
- removing: administer analgesic at least 30 mins before
procedure if it is required.
- For hemovacs you must remove the suction from the
drain before you pull it out, remove old dressing, use
sterile technique to cleanse the drain site using saline
solution (circular motion with gauze from the inside
out), you may need to cut the suture from the drain
site, apply non sterile gloves, grasp drain in the one
hand, apply counter pressure on the skin (with a
gauze) with the other hand, have client take deep
breath and slowly exhale, pull out while client exhales,
inspect drain to make sure it is complete and intact,
measure the drainage in the reservoir, cleanse the
insertion site (using sterile technique), apply light
dressing to the site, check dressing periodically to
make sure that the dressing over the drain site is dry
- empty drain: place drain on pad, do not pull on drain,
move measuring cup onto pad, open drainage port of
reservoir, tilt reservoir until it pours into the cup,
cleanse the drainage port and the plug with an alcohol
swab, squeeze reservoir with both hands so it is
evenly compressed, plug drainage port to close drain,
remove pad, measure and record the amount, color,
etc. Of fluid.

Skill 47–4 Performing Wound Irrigation

Sterile complex dressing
with packing (and
Irrigation) 1. Assess the client’s level of pain. Administer prescribed analgesic
30–45 minutes before starting wound irrigation procedure.
- Irrigation: assess 2. Review the medical record for physician’s prescription for
for pain control irrigation of open wound and type of solution to be used.
- Put pad under 3. Assess recent recording of signs and symptoms related to client’s
client to protect open wound:
bed sheet A. Condition of skin and wound
- Remove old
B. Elevation of body temperature
dressing and
C. Drainage from wound (amount, colour)
 discard, put on
new gloves D. Odour
- Draw up normal
saline into syringe, E. Consistency of drainage
allow gentle F. Size of wound, including depth, length, and width
stream onto the 4. Explain the procedure of wound irrigation and cleansing to the
wound, continue client.
until clear, liquid
5. Perform hand hygiene.
should flow out of
wound 6. Position the client comfortably to permit gravitational flow of
- Saline soaked irrigating solution through the wound and into the collection
receptacle. Position the client so that the wound is vertical to the
gauze is used to
collection basin.
fill open area,
count the number 7. Warm irrigation solution to approximately body temperature.
of pads used in the 8. Form a cuff on the waterproof bag, and place the bag near the bed.
wound. 9. Close the room door or bed curtains.
10. Put on gown and goggles, if needed.
11. Put on disposable gloves, remove soiled dressing, and discard in
waterproof bag. Discard gloves.
12. Prepare equipment; open sterile supplies.
13. Put on sterile gloves (check agency policy).
14. Irrigating a wound with a wide opening:
A. Fill a 35-mL syringe with irrigation solution.
B. Attach a 19-gauge needle or angiocatheter.
C. Hold the syringe tip 2.5 cm above the upper end of the wound
and over the area being cleansed.
D. Using continuous pressure, flush the wound; repeat Steps 14A,
B, and C until the solution draining into the basin is clear.
15. Irrigating a deep wound with a very small opening:
A. Attach a soft angiocatheter to the filled irrigating syringe.
B. Lubricate the tip of the catheter with irrigating solution; then
gently insert the tip of the catheter and pull out about 1 cm.
C. Using slow, continuous pressure, flush wound.
D. Pinch off the catheter just below the syringe while keeping the
catheter in place.
E. Remove and refill the syringe. Reconnect it to the catheter,
and repeat Steps A to D until solution draining into basin is
clear.
16. Cleanse the wound with a hand-held shower:
A. With the client seated comfortably in the shower chair, adjust
the spray to gentle flow; water temperature should be warm.
B. Cover the showerhead with a clean washcloth, if needed.
C. Have the client shower for 5–10 minutes with the showerhead
30 cm from the wound.
17. Obtain cultures, if needed, after cleansing with nonbacteriostatic
saline.
 18. Dry the wound edges with gauze; dry the client, if a shower or
whirlpool is used.
19. Apply appropriate dressing.
20. Remove gloves and, if worn, mask, goggles, and gown.
21. Dispose of equipment and soiled supplies. Perform hand hygiene.
22. Assist the client to a comfortable position.
23. Assess the type of tissue in the wound bed.
24. Inspect the dressing periodically.
25. Evaluate skin integrity.
26. Observe the client for signs of discomfort.
27. Observe for presence of retained irrigant.

- Assess need for pain medication

Care and removal of - pour saline into appropriate container, open garbage
sutures and staples. bag, dispose of dressing into garbage
Application of Steri-strips - Assess wound, cleanse would from incision outward,
pick up forceps in one hand and the suture scissors in
the other, work from the middle out, pick up the knot of
the suture with the forceps and cut with scissors
(carved end under), gently tug on knot to remove,
remove alternate sutures first and you may have to
apply suture tape
- Staples: cleanse incision with normal saline, work from
middle staple, put the two prongs under the staple,
press handle to remove staple from under the skin, lift
from skin and dispose of staple, remove alternate
staples first, cleanse skin with normal saline and apply
gauze or wound closer strips if necessary
- Stripes: remove small backing from closer strips, use
forceps to remove strip, apply one half to one end of
the wound, pull the loose end so it pulls the wound
together
- Bandages: Perform skin care, use two circular turns
Application of on the distal limb, above and around to form a figure
immobilization devices 8. Wrap previous with 2/3 the width. Allow enough
(splint, bandaging, sling) bandage to end with two circular turns. Secure with
pronged tips. Assess for circulation, sensation and
movement.
- Splints and braces: check for skin breakdown, pad
splint if necessary, position splint on limb and adjust
padding as needed, secure with a bandage, there
should be no pressure points.

Care of Suprapubic
catheters (Theory only)
Care of Peritoneal
dialysis catheters (Theory
only)

PASS ______________________

ATTEMPT #2 ________________

ATTEMPT #3 ________________
INSTRUCTOR:_____________________
NFDN – 2003 LAB 2 SKILLS (V1.09)
DATE: _________________ STUDENT NAME: __________________

SKILL COMMENTS

Measure In and Out re:

IV Therapy

Calculating IV rates

Skill 40–2 Regulating Intravenous Flow Rates

Regulating flow rate
1. Check the client’s medical record for the correct solution,
additives, and time of infusion. The usual order includes
solution for 24 hours, usually divided into 2 or 3 L. On
occasion, an intravenous (IV) order contains only 1 L to
keep the vein open (KVO). An order also indicates the time
over which each litre is to infuse.
2. Perform hand hygiene. Observe for patency of the IV line
and the needle or catheter.
A. Open the drip regulator and observe for rapid flow of
fluid from the solution into the drip chamber, and then
close the drip regulator to the prescribed rate.
3. Check the client’s knowledge of how positioning of the IV
site affects flow rate.
4. Verify with the client how the venipuncture site feels (e.g.,
determine whether the client is experiencing pain or a
burning sensation).
5. Have paper and pencil or a calculator to calculate the flow
rate.
6. Check calibration (drop factor) in drops per millilitre
(gtt/mL) of the infusion set:
A. Microdrip: 60 gtt/mL
B. Macrodrip: 15 gtt/mL or 10 gtt/mL, depending on
manufacturer (will be stated on package)
7. Calculate flow rate (hourly volume) of the prescribed
infusion.
Flow rate (mL/hr) = total infusion (volume in
millilitres) per hours of infusion (time to be infused).
8. Read the physician’s orders and follow seven rights for the
correct solution and proper additives.
9. Determine how long each litre of fluid should run. IV fluids
are usually ordered by rate, such as 100 mL/hr. On
occasion, however, IV fluids are ordered over a period of
time, such as 1000 mL D5W with 20 mmol KCl over 8 hr
10. Place adhesive or fluid indicator tape on the IV bottle or
 bag next to volume markings.

11. Select one of the following formulas to calculate minute

rate (drops/min) on the basis of the drop factor of the
infusion set:
A. mL/hr/60 min = mL/min, and drop factor × mL/min =
drops/min
B. Alternative:
mL/hr × drop factor/60 min = drops/min
Using this formula, calculate minute flow rate for bottle
1:1000 mL with 20 mmol KCl:
Microdrip:
125 mL/hr × 60 gtt/mL = 7500 gtt/hr
7500 gtt ÷ 60 minutes = 125 gtt/min
Macrodrip:
125 mL/hr × 15 gtt/mL = 1875 gtt/hr
1875 gtt ÷ 60 minutes = 31 gtt/min
12. Establish flow rate by counting drops in the drip chamber
for 1 minute by watch; then adjust the roller clamp to
increase or decrease the rate of infusion.
13. Follow this procedure for the infusion controller or pump:
A. Place the electronic eye on the drip chamber below the
origin of the drop and above the fluid level in the
chamber, or consult manufacturer’s directions for setup
of the infusion. If a controller is used, ensure that the
IV bag is 1 m above the IV site.
B. Place the IV infusion tubing within the ridges of the
control box in the direction of flow (i.e., the portion of
tubing nearest the IV bag at the top and the portion of
tubing nearest the client at the bottom), or consult
manufacturer’s directions for use of the pump. Some
devices require securing tubing through “air in line”
alarm system. Close the control chamber door. Turn on
the pump. Select required drops per minute or volume
per hour and volume to be infused. Open the rate
control clamp, and press the start button.
C. Monitor infusion rates and IV site for complications
according to agency policy.
D. Assess patency and integrity of the system when the
alarm sounds.
14. Follow this procedure for a volume control device:
A. Place the volume control device between the IV bag
and insertion spike of the infusion set, using sterile
technique.
B. Place a 2-hour allotment of fluid into the chamber
device.
 C. Assess the system at least hourly; add fluid to the
volume control device as needed. Regulate flow rate.
15. Observe the client for response to therapy and for signs of
overhydration or dehydration.
16. Evaluate infusion site for signs of infiltration,
inflammation, clot in catheter, or kink or knot in infusion
tubing.

Skill 40–3 Maintenance of an Intravenous System

Inter ? continues IV.
Maintain IV system
(gravity set and pump Changing Intravenous Solution:
set). Remove air 1. Check physician’s orders.
from line, Discontinue 2. If the order is written for keep vein open (KVO) or to keep
IV open (TKO), contact the physician for clarification of the rate
- Hang solution on of the infusion. Note date and time when solution was last
poll, close all changed.
clamps, remove 3. Determine the compatibility of all intravenous (IV) fluids and
cover from additives by consulting appropriate literature or the pharmacy.
spiked end, 4. Determine the client’s understanding of the need for continued
remove cover IV therapy.
from incision
port, insert spike 5. Assess patency of the current IV access site.
end taking care 6. Have the next solution prepared at least 1 hour before needed.
not to Check that the solution is correct and properly labelled. Check
contaminate the the solution expiration date and for the presence of precipitate
connection, and discoloration.
squeeze drip 7. Prepare to change solution when less than 50 mL of fluid
chamber until it remains in the bottle or bag or when a new type of solution is
is ½ - 1/3 full, ordered.
uncoil the tubing 8. Prepare the client and family by explaining the procedure, its
(ensure no part purpose, and what is expected of the client.
touches floor), 9. Ensure that the drip chamber is at least half full.
open clamps,
10. Perform hand hygiene.
allow fluid to
move through 11. Prepare the new solution for changing. If using a plastic bag,
tubing to remove remove the protective cover from the IV tubing port. If using a
air, once air is glass bottle, remove the metal cap and the metal and rubber
discs.
removed close
the roller clamp, 12. Move the roller clamp to stop the flow rate.
check tubing for 13. Remove the old IV fluid container from the IV pole.
air bubbles or 14. Quickly remove the spike from the old solution bag or bottle
kinks. If there are and, without touching the tip, insert the spike into the new bag
some, tap the or bottle.
tubing and flush
15. Hang the new bag or bottle of solution on the IV pole.
again.
- Changing: 48-72
hours
- Care: check 16. Check for air in the tubing. If bubbles form, the can be removed
intravenous site, by closing the roller clamp, stretching the tubing downward,
 tape intact, and tapping the tubing with your finger (the bubbles rise in the
dressing clean, fluid to the drip chamber). For larger amounts of air, swab the
follow tubing to injection port below the air with alcohol and allow to dry.
the bag looking Connect a syringe to this port and aspirate the air into the
for air bubbles syringe. Reduce air in tubing by priming slowly instead of
and kinks, check allowing a wide-open flow.
if it needs to be 17. Ensure drip chamber is one-third to half full. If the drip
changed, check chamber is too full, pinch off tubing below the drip chamber,
infusion rate invert the container, squeeze the drip chamber, hang up the
- Change bag: bottle, and release the tubing.
slow down 18. Regulate flow to the prescribed rate.
infusion rate on 19. Mark the date and time on label, and tape it on bag. Do not use
the existing set felt-tipped pens or permanent markers on intravenous bags.
up, check new 20. Observe the client for signs of overhydration or dehydration to
bag for clarity determine response to IV fluid therapy.
and leaks,
remove old bag 21. Observe IV system for patency and development of
complications (e.g., infiltration or phlebitis).
and hang up new
bag, insert spike Changing Intravenous Tubing:
end into new 22. Determine when a new infusion set is needed:
bag, make sure A. Agency policy will indicate the frequency of routine change
there is an for IV administration sets and saline flush tubing.
adequate
B. Puncture of infusion tubing necessitates immediate change.
amount of fluid in
the drip C. Contamination of tubing necessitates immediate change.
chamber, add D. Occlusions in existing tubing can occur after infusion of
more fluid once packed red blood cells, whole blood, albumin, or other
connected if blood components.
necessary, 23. Prepare the client and family by explaining the procedure, its
adjust the drip purpose, and what is expected of the client.
rate, watch
24. Perform hand hygiene.
system to ensure
the patency of 25. Open the new infusion set, keeping protective coverings over
the intravenous. the infusion spike and distal adapter. Secure all junctions with
Luer-Loks, clasping devices, or threaded devices.
- Change tubing:
put on gloves, 26. Apply nonsterile, disposable gloves.
place sterile 27. If the needle or catheter hub is not visible, remove IV dressing
gauze at the hub while maintaining the stability of the catheter. If transparent
of the catheter, dressing must be removed, place a small piece of sterile tape
bring the end of across the hub temporarily to anchor the catheter during
the new tubing disconnection. Do not remove tape securing the needle or
close to the catheter to the skin with gauze dressing.
intravenous site,
close the roller 28. For IV continuous infusion:
camp of the old
A. Move the roller clamp on new IV tubing to the closed
tubing, stabilize position.
iv catheter with
non dominant B. Slow the rate of infusion by regulating the drip rate on the
old tubing. Maintain KVO rate.
hand, with
dominant hand C. Compress and fill the drip chamber.
loosen the D. Remove the IV container from the pole, invert the
 connection of the container, and remove old tubing from the container.
old tubing, Carefully hold the container while hanging or taping the
quickly insert the drip chamber on the IV pole 1 m above the IV site.
new tubing, E. Place the insertion spike of the new tubing into the old
cleanse site if solution bag opening, and hang the solution bag on the IV
necessary and pole.
tape to secure. F. Compress and release the drip chamber on the new tubing.
Open the roller Slowly fill the drip chamber one-third to half full.
clamp and adjust
G. Slowly open the roller clamp, remove the protective cap
flow the from the needle adapter (if necessary), and flush the new
prescribed rate. tubing with solution. Replace the cap.
Add a label with
H. Turn the roller clamp on the old tubing to the closed
the date and
position.
time it was
changed. 29. For saline lock:
- Discontinue: A. If a loop or short extension tubing is needed because of an
infusion awkward IV site placement, use sterile technique to connect
complete, the new injection cap to the loop or tubing.
physician’s B. Swab the injection cap with alcohol, povidone-iodine, or
orders, site chlorhexidine. Insert the syringe with 1–3 mL saline and
infiltrated, inject through the injection cap into the loop or short
phlebitis, extension tubing.
catheter 30. Stabilize the hub of the catheter and apply pressure over the
occluded. vein just above the catheter tip, at least 3 cm above the insertion
Secure catheter site. Gently disconnect old tubing from the catheter hub.
with non Maintain stability of the hub and quickly insert the adapter of
dominant hand new tubing or saline or heparin lock into the hub.
and remove tape 31. Open the roller clamp on new tubing. Allow solution to run
with other hand, rapidly for 30–60 seconds.
slowly remove 32. Regulate the IV drip according to physician’s orders and
need with low monitor the rate hourly.
angle, once
33. Apply new dressing, if necessary.
bleeding has
stopped apply a 34. Discard old tubing in a proper container.
small adhesive 35. Remove and dispose of gloves. Perform hand hygiene.
strip to the site. 36. Evaluate the flow rate and observe the connection site for
Tip goes into a leakage.
biohazard
Discontinuing Peripheral Intravenous Access:
container, note
how the site 37. Check physician’s order for discontinuing IV therapy.
looked. 38. Explain the procedure to the client. Explain that the affected
extremity must be held still and how long the procedure will
take.
39. Perform hand hygiene, and put on disposable gloves.
40. Turn the IV tubing roller clamp to the closed position. Remove
the tape securing the tubing.
41. Remove the IV site dressing and tape while stabilizing the
catheter.
42. With dry gauze or an alcohol swab held over the site, apply
light pressure and withdraw the catheter, using a slow, steady
 movement, keeping the hub parallel to the skin.
43. Apply pressure to the site for 2–3 minutes, using the dry, sterile
gauze pad. Secure with tape.
44. Inspect the catheter for intactness, noting tip integrity and
length.
45. Discard used supplies.
46. Remove and discard gloves, and perform hand hygiene.
47. Instruct the client to report any redness, pain, drainage, or
swelling that may occur after catheter removal.

Saline locks (intensive)

Initiate, monitor,
discontinue
hypodermoclysis

Skill 34–4 Preparing Injections

Intramuscular
medications &
Intradermal 1. Check the accuracy and completeness of each MAR or
medications computer printout against the prescriber’s original medication
order. Check the client’s name and the medication name, route,
dosage, and time of administration.
2. Review pertinent information related to medication, including
its action, purpose, side effects, and nursing implications.
3. Assess the client’s body build, muscle size, and weight.
4. Perform hand hygiene and assemble the medication supplies.
5. Check the date of expiration on the medication vial or ampule.
6. Prepare medication: Ensure that you compare the label of the
medication with the MAR at least two times while preparing
the medication.
A. Ampule preparation:
(1) Tap top of ampule lightly and quickly with your
finger until the fluid moves from the neck of ampule.
(2) Place a small gauze pad or an unopened alcohol swab
around the neck of the ampule.
(3) Snap the neck of the ampule quickly and firmly away
from the hands.
(4) Draw up medication quickly, using a filter needle
long enough to reach the bottom of the ampule.
(5) Hold the ampule upside down, or set it on a flat
surface. Insert the filter needle into centre of the
ampule opening. Do not allow the needle tip or shaft
to touch the rim of the ampule.
(6) Aspirate the medication into the syringe by gently
pulling back on the plunger.
 (7) Keep the needle tip under the surface of the liquid.
Tip the ampule to bring all fluid within reach of the
needle.
(8) If air bubbles are aspirated, do not expel the air into
the ampule.

(9) To expel excess air bubbles, remove the needle from

the ampule. Hold the syringe with the needle pointing
up. Tap the side of the syringe to cause the bubbles to
rise toward the needle. Draw back slightly on the
plunger, then push the plunger upward to eject the air.
Do not eject any fluid.
(10) If the syringe contains excess fluid, dispose of it in a
sink. Hold the syringe vertically with the needle tip
up and slanted slightly toward the sink. Slowly eject
the excess fluid into the sink. Recheck the fluid level
in the syringe by holding it vertically.
(11) Cover the needle with its safety sheath or cap.
Replace the filter needle with a needle or a needleless
access device for injection.
B. Vial containing a solution:
(1) Remove the cap covering the top of the unused vial to
expose the sterile rubber seal. If a multidose vial has
been previously used, the cap has already been
removed. Firmly and briskly wipe the surface of the
rubber seal with an alcohol swab and allow it to dry.
(2) Pick up the syringe and remove the needle cap or the
cap covering the needleless vial access device. Pull
back on the plunger to draw an amount of air into the
syringe equivalent to the volume of medication to be
aspirated from the vial.
(3) With the vial on a flat surface, insert the tip of the
needle. Ensure the bevelled tip enters first, through
the centre of the rubber seal. Apply pressure to the tip
of the needle during insertion.
(4) Inject air into the vial’s airspace, holding on to the
plunger. Hold the plunger with firm pressure; the
plunger may be forced backward by air pressure
within the vial.
(5) Invert the vial while keeping a firm hold on the
syringe and plunger. Hold the vial between the thumb
and middle fingers of your nondominant hand. Grasp
the end of the syringe barrel and plunger with the
thumb and forefinger of your dominant hand to
counteract pressure in the vial.
(6) Keep the tip of the needle below the fluid level.
(7) Allow air pressure from the vial to fill the syringe
gradually with medication. If necessary, pull back
slightly on the plunger to obtain the correct amount of
solution.
 (8) When the desired volume is obtained, position the
needle into the vial’s airspace. Tap the side of the
syringe barrel carefully to dislodge any air bubbles.
Eject any air remaining at the top of the syringe into
the vial.
(9) Remove the needle from the vial by pulling back on
the barrel of the syringe.
(10) Hold the syringe at eye level, at a 90-degree angle, to
ensure the correct volume has been obtained and no
air bubbles are present. Remove any remaining air by
tapping the barrel to dislodge the air bubbles. Draw
back slightly on the plunger; then push the plunger
upward to eject the air. Do not eject the fluid.
Recheck the volume of medication.
(11) If medication is to be injected into a client’s tissue,
change needle to one of the appropriate gauge and
length according to the route of medication and the
client’s size and weight.
(12) For a multidose vial, make a label that includes the
date of mixing, the concentration of the medication
per millilitre, and your initials.
C. Vial containing a powder (reconstituting medications):
(1) Remove the cap covering the vial of powdered
medication and the cap covering the vial of proper
diluent. Firmly wipe both seals with an alcohol swab
and allow to dry.
(2) Draw up diluent into the syringe by following Steps
6B(2) through 6B(10).
(3) Insert the tip of the needle through the centre of the
rubber seal on the vial of powdered medication. Inject
the diluent into the vial. Remove the needle.
(4) Mix the medication thoroughly. Roll the vial in your
palms. Do not shake the vial.
(5) Reconstituted medication in the vial is ready to be
drawn into a new syringe. Read the label carefully to
determine the dose after reconstitution.
(6) Prepare medication in syringe, following Steps 6B(2)
through 6B(12).
7. Dispose of all soiled supplies. Place broken ampule vials, used
vials, and used needles in a puncture-proof and leak-proof
container. Clean medication work area and perform hand
hygiene.

Skill 34–5 Administering Injections

1. Check accuracy and completeness of each MAR or computer

printout against the prescriber’s original medication order.
Check the client’s name and the medication name, route,
 dosage, and time of administration. Copy or rewrite any portion
of the MAR that is difficult to read.
2. Assess the client’s medical history, medication history, and
history of allergies. Determine whether the client is allergic to
any substances and the usual allergic reaction experienced.
3. Check the date of expiration for the medication.
4. Observe client’s verbal and nonverbal responses to receiving an
injection.
5. Assess the client for contraindications:
A. For subcutaneous injections: Assess the client for factors
such as circulatory shock and reduced local tissue
perfusion. Assess the adequacy of the client’s adipose
tissue.
B. For intramuscular injections: Assess the client for muscle
atrophy, reduced blood flow, and circulatory shock.
6. Perform hand hygiene. Aseptically prepare the correct
medication dose from an ampule or vial. Ensure all air is
expelled from the syringe. Check the label of medication
against the MAR two times while preparing the medication.
Create a removable label that shows the client’s name, the name
of the drug, and the dosage. Apply the label to the removable
needle cap.
7. Bring the medication to the client at the right time, and perform
hand hygiene.
8. Close the room curtain or door.
9. Identify the client by using at least two client identifiers.
Compare the client’s name and one other identifier (e.g., the
hospital identification number) on the MAR, computer printout,
or computer screen against information on the client’s
identification bracelet. Ask the client to state his or her name, if
possible, for a third identifier.
10. Compare the label of the medication with the MAR one more
time at the client’s bedside.
11. Describe the steps of the procedure, and inform the client that
the injection will cause a slight burning or stinging sensation.
12. Perform hand hygiene; put on disposable gloves.
13. Keep a sheet or gown draped over the client’s body parts that
do not need to be exposed.
14. Select appropriate injection site. Inspect the skin surface over
the injection site for bruises, inflammation, and edema.

B. Intramuscular injection: Note the integrity and size of

muscle and palpate for tenderness or hardness. Avoid these
areas. If injections are given frequently, rotate the injection
sites. Use the ventrogluteal site if possible.
C. Intradermal injection: Note any lesions or discoloration of
client’s forearm. Select an injection site three to four
fingerwidths below the antecubital space and a handwidth
above the wrist. If the forearm cannot be used, inspect the
 client’s upper back. If necessary, sites for subcutaneous
injections may be used.
15. Assist client to a comfortable position:

B. Intramuscular injection: Position the client depending on

the site chosen (e.g., have the client sit, lie flat, lie on one
side, or lie prone).
C. Intradermal injection: Have the client extend the elbow and
support the elbow and forearm on a flat surface.
D. Speak with the client about a subject of interest.
16. Relocate the injection site by using anatomical landmarks.
17. Clean the injection site with an antiseptic swab. Touch the swab
to the centre of the site and rotate it outward in a circular
direction for about 5 cm.
18. Hold the swab or gauze between the third and fourth fingers of
your nondominant hand.
19. Remove the needle cap or sheath from the needle by pulling it
straight off.

20. Hold the syringe between the thumb and forefinger of your
dominant hand:

B. Intramuscular injection: Hold the syringe as if you were

holding a dart, palm down.
C. Intradermal injection: Hold the bevel of the needle
pointing up.
21. Administer injection.
B. Intramuscular injection:
(1) Position your nondominant hand at the proper
anatomical landmarks and pull the skin down
approximately 2.5–3.5 cm or laterally with the ulnar
side of your hand to administer the injection in a Z-
track. Hold this position until the medication is
injected. Use your dominant hand to insert the needle
quickly at a 90-degree angle into the muscle.
(2) If the client’s muscle mass is small, grasp a body of
muscle between your thumb and fingers.
(3) After needle pierces the skin, grasp the lower end of the
syringe barrel with your nondominant hand to stabilize
the syringe. Continue to hold the skin tightly with your
nondominant hand. Move your dominant hand to the
end of the plunger. Do not move the syringe.
(4) Pull back on the plunger. If no blood appears, inject the
medicine slowly, at a rate of 1 mL per 10 seconds.
(5) Wait 10 seconds, and then smoothly and steadily
withdraw the needle and release the skin. Apply gentle
pressure with dry gauze if desired.
 C. Intradermal injection:
(1) With your nondominant hand, stretch the skin over the
injection site with your forefinger or thumb.
(2) With the needle almost against the client’s skin, insert
it slowly at a 5- to 15-degree angle until resistance is
felt. Advance the needle through the epidermis to
approximately 3 mm below skin surface. The needle tip
can be seen through the skin.
(3) Inject the medication slowly. Normally, resistance is
felt. If resistance is not felt, the needle is in too deep;
remove and begin again. Your nondominant hand can
stabilize the needle during the injection.
(4) While injecting medication, notice that a small bleb
approximately 6 mm in diameter (resembling a
mosquito bite) appears on the skin’s surface. Instruct
the client that this bleb is a normal finding.
22. Withdraw the needle while applying an alcohol swab or gauze
gently over the injection site.
23. Apply gentle pressure. Do not massage the injection site. Put on
a bandage if needed.
24. Assist the client to a comfortable position.
25. Discard the uncapped needle or the needle enclosed in safety
shield and attached syringe into a puncture- and leak-proof
receptacle. Do not recap the needle.
26. Remove disposable gloves and perform hand hygiene.
27. Stay with the client 3–5 minutes to observe for any allergic
reactions.
28. Periodically return to the client’s room to ask whether the client
feels any acute pain, burning, numbness, or tingling at the
injection site.
29. Inspect the injection site, noting any bruising or induration.
30. Observe the client’s response to medication at times that
correlate with the medication’s onset, peak, and duration.
31. Ask the client to explain the purpose and effects of the
medication.
32. For intradermal injections, use a skin pencil and draw a circle
around the perimeter of the injection site. Read the site within
an appropriate amount of time, which is determined by the type
of medication or skin test administered.

Skill 34–6 Adding Medications to Intravenous Fluid Containers

Intravenous
medications
1. Check the accuracy and completeness of each MAR or
computer printout against the prescriber’s original medication
 order. Check the client’s name and the medication name, route,
dosage, and time of administration. Copy or rewrite any portion
of the MAR that is difficult to read.
2. Assess the client’s medical history.
3. Collect information necessary to administer the drug safely,
including the medication’s action, purpose, side effects, normal
dose, time of peak onset, and nursing implications.
4. When more than one medication is to be added to the
intravenous (IV) solution, assess for compatibility of the
medications.
5. Assess client’s systemic fluid balance, as reflected by skin
hydration and turgor, body weight, pulse, blood pressure, and
ratio of fluid intake to urinary output.
6. Assess client’s history of medication allergies.
7. Perform hand hygiene.
8. Assess the IV insertion site for signs of infiltration or phlebitis.
9. Assess the client’s understanding of the purpose of the
medication therapy.
10. Prepare prescribed medication; use aseptic techniques. Ensure
that you compare the label of the medication with the MAR two
times while preparing the medication.
11. Perform hand hygiene.
12. Compare the labels of the medication and the IV fluid bag with
the MAR or computer printout.
13. Add the medication to a new container (usually in the
medication room or at medication cart):
A. Solution in a bag: Locate the medication injection port on
the plastic IV solution bag. The port has a small rubber
stopper at the end. Do not select the port for the IV tubing
insertion or the air vent.
B. Solution in a bottle: Locate the injection site on the IV
solution bottle, which is often covered by a metal or plastic
cap.
C. Wipe the port or injection site with alcohol or an antiseptic
swab.
D. Remove the needle cap or sheath from the syringe and
insert the needle of the syringe or the needleless device
through the centre of the injection port or site. Inject the
medication.
E. Withdraw the syringe from the bag or bottle.
F. Mix the medication and the IV solution by holding the bag
or bottle and turning it gently end to end.
G. Complete the medication label by printing the client’s name
and dose of medication, date and time of administration,
and your initials. Apply the label to the bottle or bag; do not
cover essential information on the bottle or bag. Spike the
bag or bottle with the IV tubing.
14. Take the assembled items to client’s bedside at the right time
 and perform hand hygiene.
15. Identify the client by using at least two client identifiers.
Compare the client’s name and one other identifier (e.g., the
hospital identification number) on the MAR, computer printout,
or computer screen against information on the client’s
identification bracelet. Ask the client to state his or her name, if
possible, for a third identifier.
16. Prepare the client by explaining that the medication is to be
given through the existing IV line or a new line that will be
started. Explain that no discomfort should be felt during the
medication infusion. Encourage client to report symptoms of
discomfort.
17. Connect infusion tubing or spike container to the existing
tubing. Regulate infusion at ordered rate.
18. Add the medication to the existing container:
A. Prepare a vented IV bottle or plastic bag:
(1) Check the volume of the solution remaining in the
bottle or bag.
(2) Close off IV infusion clamp.
(3) Wipe the medication port with an alcohol or antiseptic
swab.
(4) Remove the needle cap or sheath from the syringe;
insert the syringe needle or needleless device through
the injection port and inject the medication.
(5) Withdraw the syringe from the bag or bottle.

(6) Lower the bag or bottle from the IV pole and gently
mix the medication and IV solution by holding the bag
or bottle and turning it gently from end to end. Rehang
the bag or bottle.
B. Complete the medication label and apply it to the unprinted
side of the IV solution bag or bottle. Do not cover the
imprinted label of the solution.
C. Regulate the infusion to the desired rate. Use an IV pump if
indicated.
19. Properly dispose of equipment and supplies. Do not recap the
needle or syringe. Discard sheathed needles as a unit with the
needle covered.
20. Perform hand hygiene.
21. Observe the client for signs or symptoms of medication
reaction.
23. Observe the client for signs and symptoms of fluid volume
excess.
23. Periodically return to the client’s room to assess the IV
insertion site and the rate of infusion.
24. Observe the client for signs or symptoms of IV infiltration.
 25. Ensure that a label is applied to the IV tubing; the label must
state the date and time that the IV tubing was opened and must
be attached to the IV infusion system. Consult agency policy
regarding frequency of changing IV tubing
26. Assess the IV tubing frequently for integrity and occlusions.
27. Ask the client to explain the purpose and effects of the
medication therapy.
Skill 34–7 Administering Medications by Intravenous Bolus

1. Check the accuracy and completeness of each MAR or

computer printout against the prescriber’s original medication
order. Check the client’s name and the medication name, route,
dosage, and time of administration. Copy or rewrite any portion
of the MAR that is difficult to read.
2. Collect the information necessary to administer the medication
safely, including action, purpose, side effects, normal dose,
time of peak onset, the pace at which to give the medication,
and nursing implications, such as the need to dilute the
medication or to administer it through a filter.
3. If pushing medication into an IV line, determine the
compatibility of the medication both with the IV fluids ordered
and any additives in the IV solution.
4. Perform hand hygiene. Assess the IV or saline (heparin) lock
insertion site for signs of infiltration or phlebitis.
5. Check the client’s medical history and allergies.
6. Check the date of expiration for the medication vial or ampule.
7. Assess the client’s understanding of the purpose of medication
therapy.
8. Prepare the ordered medication from the vial or ampule by
using aseptic technique. Check the label of the medication
carefully with the MAR two times. Apply a removable label
indicating the client’s name and the medication name and
dosage to the removable needle cap.
9. Bring the medication to the client at the correct time.
10. Identify the client by using at least two client identifiers.
Compare the client’s name and one other identifier (e.g., the
hospital identification number) on the MAR, computer printout,
or computer screen against information on the client’s
identification bracelet. Ask the client to state his or her name, if
possible for a third identifier.
11. Compare the label of the medications with the MAR at the
client’s bedside.
12. Explain the procedure to the client. Encourage the client to
report symptoms of discomfort at the IV site.
13. Perform hand hygiene. Put on gloves.
14. Administer the medication by IV push (through the existing IV
line):
A. Select the injection port of the IV tubing closest to the
 client. Whenever possible, the injection port should accept
a needleless syringe. Use the IV filter if required by a
medication reference manual or agency policy.
B. Wipe the injection port with an antiseptic swab. Allow to
dry.
C. Connect the syringe to the IV line. Insert the needleless tip
or a small-gauge needle of a syringe containing the
prepared drug through the centre of the injection port.
D. Occlude the IV line by pinching the tubing just above the
injection port. Pull back gently on the syringe’s plunger to
aspirate the blood return.
E. Release the tubing and inject the medication within the
amount of time recommended by institutional policy, the
pharmacist, or a medication reference manual. Use your
watch to time the administration. The IV line may be
pinched while medication is being pushed and released
when medication is not being pushed. Allow IV fluids to
infuse when the medication is not being pushed.
F. After injecting the medication, release the tubing, withdraw
the syringe, and recheck the fluid infusion rate.
15. Administer medication by IV push (IV lock or needleless
system):
A. Prepare flush solutions according to agency policy. Ensure
that a syringe with the correct barrel width is used. Consult
agency policy regarding syringes used for delivering IV
bolus medications.
(1) Saline flush method (preferred):
(a) Prepare two appropriate sized syringes with 2–3
mL of normal saline (0.9%).
(2) Heparin flush method (traditional method):
(a) Prepare one appropriate size syringe with the
ordered amount of heparin flush solution.
(b) Prepare two syringes with 2–3 mL of normal saline
(0.9%).
B. Administer medication:
(1) Wipe the lock’s injection port with an antiseptic
swab.
(2) Insert a syringe containing normal saline into the
injection port of the IV lock.
(3) Pull back gently on the syringe plunger and look for
blood return.
(4) Flush the IV lock with normal saline by pushing
slowly on plunger.
(5) Remove the saline-filled syringe.
(6) Clean the lock’s injection port with an antiseptic
swab.
(7) Insert the syringe containing the prepared medication
 into the injection port of the IV lock.
(8) Inject the medication within the amount of time
recommended by institutional policy, the pharmacist,
or a medication reference manual. Use a watch to
time the administration.
(9) After administering the bolus, withdraw the syringe.
(10) Clean the lock’s injection port with an antiseptic
swab.
(11) Attach the syringe with normal saline and inject the
normal saline flush at the same rate that the
medication was delivered.
(12) Heparin flush option: Insert the needle of the syringe
containing the heparin through the diaphragm.
16. Dispose of uncapped needles and syringes in a puncture-proof
and leak-proof container.
17. Remove and dispose of gloves. Perform hand hygiene.
18. Observe the client closely for adverse reactions while the
medication is administered and for several minutes thereafter.
19. Observe the IV site during injection for sudden swelling.
20. Observe the client’s status after the medication is administered,
to evaluate effectiveness of medication.
21. Consult agency policy with regard to the frequency of saline
flushes.
22. Ask the client to explain the medication’s purposes and side
effects.
Skill 34–8 Administering Intravenous Medications by Piggyback,
Intermittent Intravenous Infusion Sets, and Mini-Infusion Pumps

1. Check the accuracy and completeness of each MAR or

computer printout against the prescriber’s original medication
order. Check the client’s name and the medication name, route,
dosage, and time of administration. Copy or rewrite any portion
of the MAR that is difficult to read.
2. Determine the client’s medical history.
3. Collect the information necessary to administer the medication
safely, including the action, purpose, side effects, normal dose,
time of peak onset, and nursing implications, such as the need
to dilute the medication or administer it through a filter.
4. Assess the compatibility of the drug with the existing IV
solution.
5. Assess patency of the client’s existing IV infusion line by the
noting infusion rate of the main IV line.
6. Perform hand hygiene. Assess IV insertion site for signs of
infiltration or phlebitis: redness, pallor, swelling, tenderness on
palpation.
7. Assess the client’s history of medication allergies.
8. Assess the client’s understanding of the purpose of medication
therapy.
9. Prepare the medication. Ensure that you compare the label of
the medication with the MAR two times while preparing the
medication.
10. Assemble supplies at the client’s bedside. Prepare the client by
explaining that the medication will be given through the IV
equipment.
11. Perform hand hygiene.
12. Identify the client by using at least two client identifiers.
Compare the client’s name and one other identifier (e.g., the
hospital identification number) on the MAR, computer printout,
or computer screen against information on the client’s
identification bracelet. Ask the client to state his or her name, if
possible, for a third identifier.
13. Compare medication label with MAR at the client’s bedside.
14. Explain to the client the purpose of the medication and its side
effects. Encourage the client to report symptoms of discomfort
at the injection site.
15. Administer the infusion:
A. Piggyback or tandem infusion:
(1) Connect the infusion tubing to the medication bag.
Allow the solution to fill the tubing by opening the
regulator flow clamp. Once the tubing is full, close the
clamp and cap the end of the tubing.
(2) Hang the piggyback medication bag above the level of
the primary fluid bag. (A hook may be used to lower
the main bag.) Hang the tandem infusion bag at the
same level as the primary fluid bag.
(3) Connect the tubing of the piggyback or tandem infusion
to the appropriate connector on the primary infusion
line:
(a) Stopcock: Wipe the stopcock port with an alcohol
swab and connect the tubing. Turn the stopcock to
the open position.
(b) Needleless system: Wipe the needleless port, and
insert the tip of the piggyback or tandem infusion
tubing.
(c) Tubing port: Connect the sterile needle to the end
of the piggyback or tandem infusion tubing,
remove the cap, clean the injection port on the main
IV line, and insert the needle or needleless access
device through the centre of the port. Secure by
taping the connection.
(4) Regulate the flow rate of the medication solution by
adjusting the regulator clamp. (Infusion times vary.
Refer to a medication reference manual or institutional
policy for the safe flow rate.)
 (5) After medication has infused, check the flow regulator
on the primary infusion. The primary infusion should
automatically begin to flow after the piggyback or
tandem solution is empty.
(6) Regulate the main infusion line to the desired rate, if
necessary.
(7) Leave the IV piggyback bag and tubing in place for
future medication administration or discard in
appropriate containers.

B. Volume-control administration set (e.g., Volutrol):

(1) Assemble the supplies in the medication room.
(2) Prepare medication from a vial or ampule.
(3) Fill the Volutrol with the desired amount of fluid (50–
100 mL) by the opening clamp between the Volutrol
and the main IV bag.
(4) Close the clamp and ensure the clamp on the air vent of
the Volutrolchamber is open.
(5) Clean the injection port on the top of the Volutrol with
an antiseptic swab.
(6) Remove the needle cap or sheath and insert the syringe
needle through the port, then inject medication. Gently
rotate the Volutrol between your hands.
(7) Regulate the IV infusion rate to allow the medication to
infuse in time recommended by institutional policy, a
pharmacist, or a medication reference manual.
(8) Label the Volutrol with the name of the medication, the
dosage, the total volume (including the diluent), and the
time of administration.
(9) Dispose of the uncapped needle or the needle enclosed
in the safety shield and syringe in a proper container.
Perform hand hygiene.
C. Mini-infusion administration:
(1) Connect prefilled syringe to the mini-infusion tubing.
(2) Carefully apply pressure to the syringe plunger,
allowing the tubing to fill with medication.
(3) Place the syringe into mini-infusor pump (follow
product directions). Ensure the syringe is secure.
(4) Connect the mini-infusion tubing to the main IV line:
(a) Stopcock: Wipe the stopcock port with an alcohol
swab and connect the tubing. Turn the stopcock to
the open position.
(b) Needleless system: Wipe the needleless port and
insert the tip of the mini-infusor tubing.
(c) Tubing port: Connect the sterile needle to the mini-
 infusion tubing, remove the cap, clean the injection
port on the main IV line, and insert the needle
through the centre of port. Consider placing tape
where the IV tubing enters the port to secure the
connection.

(5) Explain the purpose of the medication and the side

effects to the client, and explain that the medication is
to be given through the existing IV line. Ask the client
to report any symptoms of discomfort at the injection
site.
(6) Hang the infusion pump with the syringe on the IV pole
alongside the main IV bag. Set the pump to deliver
medication within the time recommended by
institutional policy, the pharmacist, or a medication
reference manual. Press the button on the pump to
begin infusion. Optional: Set the alarm.
(7) After medication has infused, check the flow regulator
on the primary infusion. The infusion should
automatically begin to flow once the pump stops.
Regulate the main infusion line to the desired rate as
needed. (Note: If the stopcock is used, turn off the
mini-infusion line.)
16. Observe the client for signs of adverse reactions.
17. During infusion, periodically check the infusion rate and the
condition of the IV site.
18. Ask the client to explain the purpose and side effects of the
medication.

Monitoring and care of

client with TPN (total
paternal nutrition)
(Theory only)

- Normal saline is the only solution that can safely be

Care of and used with transfusion products, remove saline from
discontinuing blood package and hang on pole, take y set tubing and close
Transfusions all clamps, remove cover from one spike end and insert
into insertion port of iv bag. Open roller clamp to iv bag,
fill until drip chamber is ½ full, uncoil tubing, open clamp
and release air from tubing, close roller clamp once all
air is removed. With a registered nurse verify the
doctor’s order (info on blood bag to client chart), read
outloud the client’s spelling of full name, birth date and
id number with two people (RN), obtain a baseline set of
vital signs: pulse, temperature, respiration, blood
pressure. RN initiate the blood transfusion, the LPN can
adjust the rate on direction of the RN or physician, vitals
 are monitored every 5 minutes (adverse reactions occur
in the first 15 mins), report changes to vital signs. After
15 mins, continue to monitor every 15-30 mins until the
transfusion is complete (approx. 4 hours), if there is a
reaction, switch client to normal saline and report to the
physician or nurse at once. When transfusion is
complete, close the clamp to the blood bad and open
the clamp to the saline bag, flush tubing to remove any
remaining blood product in the administration set, run
normal saline at a rate to keep the vein open or
according to the rate prescribed by the physician
Skill 40–1 Initiating a Peripheral Intravenous Infusion
IV Initiation

1. Review the physician’s order for the type and amount of

intravenous (IV) fluid, rate of fluid administration, and purpose
of infusion. Follow seven rights for administration of
medications.
2. Observe the client for signs and symptoms indicating fluid or
electrolyte imbalances that may be affected by IV fluid
administration:
A. Peripheral edema
B. Greater than 20% change in body weight
C. Dry skin and mucous membranes
D. Distended neck veins
E. Blood pressure changes
F. Irregular pulse rhythm; tachycardia
G. Auscultation of abnormal lung sounds
H. Decreased skin turgor
I. Thirst
J. Anorexia, nausea, and vomiting
K. Decreased urine output
L. Behavioural changes
3. Assess the client’s prior or perceived experience with IV
therapy and arm placement preference.
4. Determine whether the client is to undergo any planned
surgeries or is to receive blood infusion later.
5. Assess laboratory data and client’s history of allergies.
6. Assess for the following risk factors: child or older adult,
presence of heart failure or renal failure, or low platelet count.
7. Prepare the client and family by explaining the procedure, its
purpose, and what is expected of the client.
8. Perform hand hygiene.
9. Assist the client to a comfortable sitting or supine position.
10. Organize equipment on a clean, cutter-free bedside stand or
overbed table.
11. Change the client’s gown to a more easily removable gown
with snaps at the shoulder, if available.
12. Open sterile packages, using sterile aseptic technique.
13. Check IV solution, using the rights of drug administration.
Make sure prescribed additives (e.g., potassium, vitamins) have
been added. Check solution for colour, clarity, and expiration
date. Check bag for leaks, which is best if done before reaching
the bedside.
14. Open the infusion set, maintaining sterility of both ends of
tubing. Many sets allow for priming of tubing without removal
of end cap.
15. Place a roller clamp about 2–5 cm below the drip chamber and
move the roller clamp to closed position.
16. Remove the protective sheath over the IV tubing port on the
plastic IV solution bag. For bottled IV solution, remove the
metal cap and the metal and rubber discs beneath the cap. Use
caution to avoid touching the exposed opening.
17. Insert the infusion set into the fluid bag or bottle by removing
the protector cap from the tubing insertion spike (keeping the
spike sterile), and inserting the spike into the opening of the IV
bag. Cleanse the rubber stopper on the glass-bottled solution
with antiseptic, and insert the spike into the black rubber
stopper of the IV bottle. Hang the solution container on the IV
pole at a minimum height of 90 cm above the planned insertion
site.
18. Compress the drip chamber and release, allowing it to fill one
third to one half full. Open the clamp and prime the infusion
tubing by filling with IV solution, carefully inverting valves
and ports in sequence as the solution moves through the tubing.
19. Remove the tubing protector cap (some tubing can be primed
without removal) and slowly release the roller clamp to allow
fluid to travel from the drip chamber through the tubing to the
needle adapter. Return the roller clamp to the closed position
after the tubing is primed (filled with IV fluid).
20. Be certain that the tubing is clear of air and air bubbles. To
remove small air bubbles, firmly tap the IV tubing where air
bubbles are located. Check the entire length of tubing to ensure
that all air bubbles are removed.
21. Replace the tubing cap protector on the end of the tubing.
22. Optional: Prepare normal saline lock for infusion. Use a sterile
technique to connect the IV plug to the loop or short extension
tubing. Inject 1–3 mL of normal saline through the plug and
through the loop or short extension tubing.

23. Put on disposable gloves. Eye protection and a mask may be

worn if splash or spray of blood is possible. Note: Gloves can
be left off to locate a vein but must be put on before the site is
prepared.
24. Identify an accessible vein for IV placement. Place a tourniquet
10–15 cm above the proposed insertion site. Position the
tourniquet so that the ends are away from the site. Check for the
 presence of the radial pulse. Option: Apply a blood pressure
(BP) cuff instead of a tourniquet. Inflate the cuff to a level just
below the client’s normal diastolic pressure. Maintain inflation
at that pressure until the venipuncture is completed.
25. Select the vein. Common intravenous sites for the adult include
cephalic, basilic, and median cubital veins:
A. Use the most distal site in the client’s nondominant arm, if
possible.
B. Avoid areas that are painful to palpation.
C. Select a vein large enough for catheter placement.
D. Choose a site that will not interfere with the client’s
activities of daily or planned procedures.
E. Use the fingertips to palpate the vein by pressing downward
and noting the resilient, soft, bouncy feeling as the pressure
is released.
F. Promote venous distension by instructing the client to open
and close the fist several times, lowering the client’s arm in
a dependent position, applying warmth to the arm for
several minutes, and rubbing or stroking the client’s arm
from distal to proximal below the proposed site.
G. Avoid sites distal to the previous venipuncture site,
sclerosed or hardened cordlike veins, infiltrated site or
phlebitic vessels, bruised areas, and areas of venous valves
or bifurcation. Avoid veins in the antecubital fossa and
ventral surface of the wrist.
H. Avoid fragile dorsal veins in older adults and vessels in an
extremity with compromised circulation (e.g., in cases of
mastectomy, dialysis graft, or paralysis).
26. Release tourniquet temporarily. Clip arm hair with scissors (if
necessary). Do not shave the area.

27. (If area of insertion appears to need cleansing, use soap and
water first.) Cleanse the insertion site, using a firm, circular
motion (centre to outward) in concentric circles 5 to 7.5 cm
from the insertion site. Use antiseptic preparation as a single
agent or in combination, according to agency policy. Two
percent chlorhexidine gluconate is the antiseptic cleansing
agent of choice. Povidone-iodine is a topical anti-infective
agent that reduces skin surface bacteria; 70% alcohol is another
antiseptic cleansing agent. Povidone-iodine must dry to be
effective in reducing microbial counts. Avoid touching the
cleansed site. Allow the site to dry for at least 2 minutes. If the
skin is touched after cleansing, repeat cleansing procedure.
28. Reapply tourniquet or BP cuff.
29. Perform venipuncture. Anchor the vein by placing your thumb
over the vein beneath the insertion site and by stretching the
skin against the direction of insertion 5–7.5 cm distal to the site.
Warn the client of a sharp stick. Puncture skin and vein,
holding the catheter at a 10- to 30-degree angle with bevel
pointed upward.
A. Butterfly needle: Hold the needle at a 10- to 30-degree
angle with bevel up, slightly distal to the actual site of
venipuncture.
B. Needleless over-the-needle catheter (ONC) safety device:
Insert ONC with bevel up, at a 10- to 30-degree angle,
slightly distal to the actual site of venipuncture in the
direction of the vein.
30. Look for blood return through the tubing of the butterfly needle
or flashback chamber of the ONC, indicating that the needle has
entered the vein. Lower the catheter or needle until almost flush
with the skin. Advance the butterfly needle until the hub rests at
the venipuncture site. Advance the ONC 0.5 cm into the vein
and then loosen the stylet. Advance the catheter off the stylet
into the vein until the hub rests at the venipuncture site. Do not
reinsert the stylet once it is loosened. (Advance the safety
device by using the push-tab to thread the catheter.)
31. Stabilize the catheter. Apply gentle but firm pressure with the
index finger of your nondominant hand 3 cm above the
insertion site. Release the tourniquet or BP cuff you’re your
dominant hand, and retract the stylet from ONC. Do not recap
the stylet. For a safety device, slide the catheter off the stylet
while gliding the protective guard over the stylet. A click
indicates that the device is locked over the stylet.
32. Quickly connect the adapter of the primed fluid administration
set or saline lock to the hub of the ONC or butterfly tubing. Be
sure the connection is secure. Do not touch the point of entry of
the adapter.
33. Release the roller clamp slowly to begin infusion at a rate to
maintain patency of the IV line.
A. Intermittent infusion: Continue to stabilize the catheter with
your nondominant hand, and attach the injection cap of the
adapter. Insert prefilled flush solution into the injection cap.
Flush slowly. Maintain thumb pressure on the syringe
during withdrawal, or close the clamp on the extension
tubing of the injection cap while still flushing the last 0.2–
0.4 mL of flush solution.
34. Tape or secure the catheter:
A. If applying transparent dressing: Secure the catheter with
your nondominant hand while preparing to apply dressing.
B. If applying a gauze dressing:
(1) Tape the IV catheter. Place a narrow piece (1-cm wide)
of sterile tape under the hub of the catheter with
adhesive side up, and criss-cross tape over the hub to
form a chevron.
(2) Place tape only on the catheter, never over the insertion
 site. Secure the site to allow easy visual inspection and
early recognition of infiltration and phlebitis. Avoid
applying tape around the extremity.
C. Observe the site for swelling.
35. Apply sterile dressing over the site.
A. Transparent dressing:
(1) Carefully remove adherent backing. Apply one edge of
dressing and then gently smooth remaining dressing
over the site, leaving the end of the catheter hub
uncovered. Refer to the manufacturer’s directions.
(2) Take a 2.5-cm piece of tape and place it from the end of
the catheter hub to the insertion site, over transparent
dressing.
(3) Apply chevron and place only over the tape, not the
transparent dressing.
B. Sterile gauze dressing:
(1) Fold 2 × 3 × 2 gauze in half and cover with a 2.5-cm-
wide piece of sterile tape extending about 2.5 cm from
each side. Place under tubing–catheter hub junction.
Place a 2 × 2 gauze pad over venipuncture site and
catheter hub. Secure edges with tape.
(2) Curl a loop of tubing alongside the arm and place a
second piece of tape directly over the 2 × 2 gauze,
securing tubing in two places.

36. Prepare the equipment according to expected frequency of use:

A. For IV fluid administration: Adjust the flow rate to correct
drops per minute or connect to electronic infusion device
(EID).
B. For intermittent use: Saline lock. Flush with 3 mL of sterile
normal saline at prescribed frequency or per agency policy.
37. Label dressing with date, time, gauge size and length of
catheter, placement of IV line and dressing, and your initials.
38. Dispose of used needles in an appropriate sharps container.
Discard supplies. Remove gloves and perform hand hygiene.
39. Observe the client every hour to determine whether fluid is
infusing correctly:
A. Check whether the correct amount of solution is infused as
prescribed by looking at the time tape.
B. Count the flow or check the rate on the infusion pump.
C. Check the patency of the IV catheter or needle.
D. Observe the client for signs of discomfort.
E. Inspect the insertion site for absence of phlebitis,
infiltration, or inflammation.
40. Observe the client every hour to determine response to therapy
(i.e., measure vital signs, conduct postprocedure assessments).
PASS ______________________
ATTEMPT #2 ________________
ATTEMPT #3 ________________
INSTRUCTOR:_____________________
NFDN – 2003 LAB 3 SKILLS (V1.09)

DATE: _________________ STUDENT NAME: __________________

SKILL COMMENTS
Skill 45–2 Inserting and Maintaining a Nasogastric Tube
Nasogastric tube
insertion, related
nursing care and 1. Perform hand hygiene. Inspect the condition of the
removal of client’s nasal and oral cavities.
2. Ask whether the client has a history of nasal surgery,
- Auscultate the and note whether a deviated nasal septum is present.
abdomen for 3. Palpate the client’s abdomen for distension, pain, and
presence of bowel rigidity. Auscultate for bowel sounds.
sounds, palpate,
4. Assess the client’s level of consciousness and ability to
determine the
follow instructions.
amount of
abdominal 5. Check the medical record for the surgeon’s order, the
distention, place in type of nasogastric tube to be placed, and whether the
high fowlers (or 45 tube is to be attached to suction equipment.
degrees), check 6. Perform hand hygiene. Prepare equipment at the
nares for patency bedside. Cut a piece of tape approximately 10 cm long
by having client and split one end in half to form a “V,” or have the
occlude one nostril nasogastric tube fixator device available.
at a time, select 7. Identify the client and explain the procedure.
the nostril that has 8. Put on disposable gloves.
the best patency
9. Position the client in a high Fowler’s position with
- Place towel on pillows behind the head and shoulders. Raise the bed to
patient’s chest, a horizontal level that is comfortable for you.
measure from
10. Place a bath towel over the client’s chest; give facial
nose the tip of the
tissues to the client. Place the emesis basin within
earlobe to the reach.
bottom of the
xiphoid process, 11. Pull the curtain around the bed, or close the room door.
mark tube. 12. Stand on the client’s right side if you are right-handed,
- Lubricate tip at on the left side if you are left-handed.
least 1-2 inches, 13. Instruct the client to relax and breathe normally while
insert tube into you occlude one naris. Repeat this action for the other
nostril (back and naris. Select the nostril with the greater airflow.
down), have client 14. Measure the distance to insert the tube:
swallow while
A. Measure the distance from the tip of the client’s
pushing tube
nose to the earlobe and then to the xiphoid process.
forward, provide
fluids to encourage
swallowing,
swallowing causes B. Mark the 50-cm point on the tube, then take a
the epiglottis to traditional measurement. The tube should be
cover the trachea inserted to a midway point between 50 cm and the
- Rotate tube if
resistance is traditional mark.
encountered, stop 15. Mark the length of tube to be inserted by using a small
if signs of distress piece of tape placed so that it can easily be removed.
(gasping,
16. Curve 10–15 cm of the end of the tube tightly around
coughing,
your index finger, then release.
cyanosis, inability
to speak), secure 17. Lubricate 7.5–10 cm of the end of the tube with water-
tube to nose with soluble lubricating jelly.
tape, cut 20 cm 18. Alert the client that the procedure is to begin.
piece of tape, split 19. Instruct the client to extend the neck back against the
the bottom half. pillow; insert the tube gently and slowly through the
Put top half on naris with the curved end pointing downward.
nose and wrap 20. Continue to insert the tube along the floor of the nasal
bottom half around passage aiming down toward the client’s ear. If
tubing, use syringe resistance is met, apply gentle downward pressure to
and aspirate advance the tube (do not force the tube past the area of
stomach contents resistance).
to ensure you are 21. If resistance is met, try to rotate the tube to see whether
in the right spot, it advances. If resistance continues, withdraw the tube,
attach to the allow the client to rest, relubricate the tube, and insert
suction (drains the tube into the other naris.
gastric contents – 22. Continue insertion of tube by gently rotating the tube
decompression of toward the opposite naris. Insert until the tube is just
stomach), secure past the nasopharynx.
tube to gown A. Stop the tube advancement; allow the client to
relax. Provide the client with tissues.
B. Explain to the client that the next step requires that
the client swallow. Give the client a glass of water,
unless this is contraindicated.
23. With the tube just above the oropharynx, instruct the
client to flex the head forward, while you place your
hand at the back of the neck to support it. Have the
client take a small sip of water and swallow. Advance
the tube 2.5–5 cm with each swallow of water. If client
is not allowed fluids, instruct the client to dry swallow
or to suck air through a straw.
24. If the client begins to cough, gag, or choke, withdraw
the tube slightly (do not completely remove the tube)
and stop tube advancement. Instruct the client to
breathe easily and take sips of water.

25. If the client continues to gag and cough or if the client

complains that the tube feels as though it is coiling in
the back of the throat, check the back of the oropharynx
using a tongue blade. If the tube has coiled, withdraw it
until the tip is back in the oropharynx. Reinsert the tube
while the client swallows.
26. Continue to advance the tube with swallowing until the
tape or mark on the tube is reached. Temporarily
anchor the tube to the client’s cheek with a piece of
 tape until the tube placement is checked.
27. Verify tube placement. Check agency policy for the
preferred methods for checking nasogastric tube
placement:
A. Ask the client to talk.
B. Inspect the posterior pharynx for the presence of
coiled tube.
C. Aspirate gently back on the syringe to obtain
gastric contents. Note the colour and other
characteristics.
D. Measure the pH of the aspirate with colour-coded
pH paper with a range of whole numbers 1 to 11.
E. Have an X-ray examination performed of the chest
or abdomen.
F. If the tube is not in the stomach, advance another
2.5–5 cm and repeat steps 27B, C, and D to check
the tube position.
28. Anchor the tube:
A. After the tube is properly inserted and positioned,
either clamp the end or connect the end to the
drainage bag or a suction machine.
B. Tape the tube to the nose; avoid putting pressure on
both nares.
(1) Before taping the tube to the nose, apply a
small amount of tincture of benzoin to the
lower end of the nose and allow it to dry
(optional). Ensure the top end of the tape over
the nose is secure.
(2) Carefully wrap the two split ends of tape
around the tube.
(3) Alternative: Apply the tube fixation device by
using a shaped adhesive patch.

C. Fasten the end of the nasogastric tube to the client’s

gown by looping a rubber band around the tube
into a slip knot. Pin the rubber band to the client’s
gown (to provide slack for movement).
D. Unless the physician orders otherwise, the head of
the bed should be elevated 30 degrees.
E. Explain to the client that the sensation of the tube
will decrease with time.
F. Remove gloves and perform hand hygiene.
29. Once placement is confirmed:
A. Place a mark, either a red mark or tape, on the tube
to indicate where the tube exits the nose.
B. Alternatively, measure the length of the tube from
 the naris to the connector.
C. Document the tube length in the client’s record.
30. Tube irrigation:
A. Perform hand hygiene, and put on gloves.
B. Check for tube placement in the stomach (see Step
27). Reconnect the nasogastric tube to the
connecting tube.
C. Draw up 30 mL of normal saline into Asepto or
catheter-tipped syringe.
D. Clamp the nasogastric tube. Disconnect from the
connection tubing, and lay the end of the
connection tubing on a towel.
E. Insert the tip of the irrigating syringe into the end
of the nasogastric tube. Remove the clamp. Hold
the syringe with the tip pointed at the floor and
inject the saline slowly and evenly. Do not force
the solution.
F. If resistance occurs, check for kinks in the tubing.
Turn the client onto the left side. Repeated
resistance should be reported to the physician.
G. After instilling saline, immediately aspirate or pull
back slowly on the syringe to withdraw fluid. If the
amount aspirated is greater than amount instilled,
record the difference as output. If the amount
aspirated is less than amount instilled, record the
difference as intake.

H. Reconnect the nasogastric tube to the drainage bag

or suction equipment (if the solution does not
return, repeat the irrigation.)
I. Remove gloves and perform hand hygiene.
31. Observe the amount and character of the contents
draining from the nasogastric tube. Ask whether the
client feels nauseated.
32. Palpate the client’s abdomen periodically, noting any
distension, pain, or rigidity. Turn off the suction, and
auscultate for the presence of bowel sounds.
33. Inspect the condition of the nares and the nose.
34. Observe the position of the tubing.
35. Ask whether the client has a sore throat or feels
irritation in the pharynx.
36. Discontinuation of a nasogastric tube:
A. Verify the order to discontinue the nasogastric tube.
B. Explain the procedure to the client and reassure the
client that removal is less distressing than insertion.
 C. Perform hand hygiene and put on disposable
gloves.
D. Turn off the suction and disconnect the nasogastric
tube from the drainage bag or suction equipment.
Remove tape from the bridge of the client’s nose
and unpin the tube from the gown.
E. Stand on the client’s right side if you are right-
handed, on the left side if you are left-handed.
F. Hand the client a facial tissue; place a clean towel
across the chest. Instruct the client to take a deep
breath and to hold the breath.
G. While the client holds the breath, clamp or kink the
tubing securely and then pull the tube out steadily
and smoothly into a towel held in your other hand.
H. Measure the amount of drainage, and note the
character of the contents. Dispose of the tube and
drainage equipment into the proper container.
I. Clean the client’s nares and provide mouth care.
J. Position the client comfortably and explain the
procedure for drinking fluids, if they are not
contraindicated.
37. Clean the equipment and return to their proper place.
Place soiled linen in the utility room or the proper
receptacle.
38. Remove gloves and perform hand hygiene.
39. Inspect the condition of the client’s nares and nose.
40. Ask whether the client has a sore throat or feels
irritation in the pharynx.
- Female: put pad under buttocks and provide peri care
Insertion, care and if necessary, place in supine position with her knees
removal of urinary flexed and legs apart, support sides with pillows if
catheters necessary, using bath blanket or drape cover her so
that only the perineum is exposed. Position tray so
your dominant hand will have easy access to the tray
and the perineum. Place catheter bag on bed beside
client, apply gloves, position garbage bag for easy
access, set up tray, coil catheter in your hand, place
catheter into the tray, open the package of cleansing
solution and water soluble lubricant, squeeze
lubricant onto sterile field. Insert syringe into balloon
port of catheter, inflate to ensure it is not damaged,
dip catheter tip into the lubricant, using drapes create
a sterile field, place one on the bed and the other
around the perineum, be careful of your gloves, place
the tray on the drape on the bed, using your non
dominant hand spread the labia to expose the
meatus, cleans the meatus from top to bottom using
one gauze, hold catheter 2-5 cm from the tip, ask
client to take deep breath and slowly exhale, gently
 insert catheter until urine starts to flow out, insert 2.5
– 5 cm futher to ensure you can inflate the balloon,
gently pull on catheter to ensure placement. Pick up
connector end of the bag in your dominant hand,
clean any cleaning solution if necessary, place urine
bag below the client, reposition client.
- Male: put pad under buttocks and drape so the
genitals are exposed, knees should be bent and
thighs slightly apart, set up tray the same way, test
balloon, lubricate catheter, create a sterile field with
drapes, place tray on drape, cleanse the meatus, hold
penis with non dominant hand do not remove hand,
make penis perpendicular to the body, have client
breath and slowly exhale, slowly insert the catheter,
urine will flow out, follow same steps as for female.
- Removal: empty drainage bag and measure contents,
position pad under client’s buttocks, insert syringe
into the balloon port of the catheter and withdraw the
fluid, slowly pull on the catheter to remove, provide
peri care, instruct the client to inform you when they
first go to the bathroom so you can measure their
output, if client has not voided in 4 hours report this to
the nurse in charge.
- Non dominant hand picks up glove for dominant hand
Sterile gloves

Rinse away debris and help reduce infection, or instil

Manual, intermittent and medication and maintain patency of urinary drainage
continuous system.
bladder irrigation - Check chart for order
- Assess urine characteristics and patency of catheter
- Feel stomach
- Wash hands
- Introduce and explain, raise bed, provide privacy
- Place pad under catheter connection
- Place disposable bag within reach, assemble tray,
apply gloves
- Pour solution into the bottle or bowl on the tray, drape
him to expose the connection to the drainage tube
- Cleanse the connector site, disconnect drainage tube
to the catheter
- Place sterile connective cover over the end of the
drainage tube, tuck the end of the tube under the
sheet, place the plastic tray onto the disposable pad,
let the catheter rest in the tray.
- Using dominant hand draw up 30-50 mL of irrigant
solution, insert into the catheter end and slowly
release into the bladder, disconnect and let the
catheter tip drain into the tray by gravity, repeat as
ordered, or until it flows clearly and free of debris.
 Keep track of how much fluid you use. Reconnect
tubing, lower the bed. Measure output. Wash hands.
- Bivalve is making two cuts along the length, put drape
Care and removal of under limb, use up and down motion to show it does it
casts cut, support the limb with your free hand, hold saw
with your fingers and guide with your thumb, cut by
pushing down on the cast with the saw and then
pulling out and moving over, pushing down again,
separate cast using cast spreaders. Cut soft plaster
areas with the scissors. Cut bandage underneath with
bandage scissors. If bivalve, tape the cast in place to
stabilize the limb.
- Cast window for dressing changes or to observe, tape
window back on when done (wrap tape around).

Care of joint
replacements

- Have someone help you, have them support the leg

Care of traction and while you remove the weight, slowly lower to the bed.
external fixators remove boot and check skin for areas of breakdown,
provide skin care. Reapply boot and fasten straps,
connect the boot to the traction apparatus, inspect the
cord that passes through the boot and to the pully
and ends in an orthopaedic knot, the knot should be
taped so it does not come untied, make sure the
weight holder has the ordered amount of weight,
adjust pulley and limb so they are properly aligned,
assess both limbs to determine neurovascular status,
cap refill, sensitivity, movement and warmth of each
limb, ensure heel is off bed. Weight should be off the
floor (hanging).

PASS ______________________

ATTEMPT #2 ________________

ATTEMPT #3 ________________
INSTRUCTOR:_____________________
NFDN – 2003 LAB 4 SKILLS (V1.09)

DATE: _________________ STUDENT NAME: __________________

SKILL COMMENTS
Skill 39–4 Applying a Nasal Cannula or Oxygen Mask
Oxygen therapy via
mask
1. Inspect the client for signs and symptoms associated with
- Baseline vitals hypoxia and the presence of airway secretions.
- Pulse oximetry 2. Obtain the client’s most recent SpO2 or arterial blood gas
and lung sounds (ABG) values.
- Increase oxygen 3. Explain to the client and family what the procedure entails and
slowly, assess the purpose of oxygen therapy.
client in 15
4. Perform hand hygiene.
minutes and
compare to 5. Attach the nasal cannula to the oxygen tubing, and attach the
baseline data tubing to the humidified oxygen source, adjusted to the
prescribed flow rate.
6. Place tips of the cannula into the client’s nares. Adjust the
elastic headband or plastic slide until the cannula fits snugly
and comfortably.
7. Maintain sufficient slack on the oxygen tubing, and secure
tubing to the client’s clothes.
8. Check the cannula every 8 hours. Keep the humidification jar
filled at all times.
9. Observe the client’s nares and the superior surface of both ears
for skin breakdown.
10. Perform hand hygiene.
11. Check the oxygen flow rate and physician’s orders every 8
hours.
12. Inspect the client for relief of symptoms.

- Auscultate the lung fields, assist into appropriate

Chest physio position, place tissues and garbage within their reach,
cover the area to be percussed with a towel,
encourage client to breathe deeply, cup hands and tap
on chest for 1-2 mins, encourage client to cough and
expectorate secretions, vibration: place flat palms
down on chest (under breasts) and vibrate rapidly
during exhalation repeat for 5 exhalations,
Skill 39–1 Suctioning
Nasopharyngeal and
Oropharyngeal
suctioning 1. Assess for signs and symptoms of upper and lower airway
obstruction necessitating nasotracheal or orotracheal
- Assess client’s suctioning; abnormal respiratory rate; adventitious sounds;
need for suctioning nasal secretions, gurgling, drooling; restlessness; gastric
(auscultate lung secretions or vomitus in the mouth; and coughing without
sounds), for a clearing secretions from the airway.
conscious client 2. Assess for signs and symptoms associated with hypoxia and
use a semi fowlers hypercapnia: decreased SpO2, increased pulse and blood
position with their pressure, increased respiratory rate, apprehension, anxiety,
head turned decreased ability to concentrate, lethargy, decreased level of
towards you, if consciousness (especially acute), increased fatigue, dizziness,
they are behavioural changes (especially irritability), dysrhythmias,
unconscious use a pallor, and cyanosis.
lateral toward 3. Determine factors that normally influence upper or lower
position so you are airway functioning: fluid status; lack of humidity; pulmonary
facing them. Turn disease, chronic obstructive pulmonary disorder, and
suction source on pulmonary infection; anatomy; changes in level of
and adjust suction consciousness; and decreased cough or gag reflex.
(between 100 – 4. Identify contraindications to nasotracheal suctioning: occluded
170 mm mercury nasal passages; nasal bleeding, epiglottitis, or croup; acute
for adult suction), head, facial, or neck injury or surgery, coagulopathy, or
open water/saline, bleeding disorder; irritable airway or laryngospasm or
bronchospasm; gastric surgery with high anastomosis; or
open catheter
myocardial infarction.
package, apply
gloves, measure 5. Examine sputum microbiology data.
the distance from 6. Assess the client’s understanding of the procedure.
the tip of the nose 7. Obtain a physician’s order if indicated by agency policy.
to the earlobe
(15cms to 5 inces), 8. Explain to the client how the procedure will help clear the
airway and relieve breathing problems and that temporary
with the non
coughing, sneezing, gagging, or shortness of breath is normal.
dominant hand Encourage the client to cough out secretions. Have the client
pick up the suction practise coughing, if able. Splint surgical incisions, if
connecting tube, necessary.
connect the two
9. Explain the importance of coughing, and encourage coughing
tubes, hold the during the procedure.
suction control in
your non dominant
hand, dip the tip
into the saline to 10. Help the client to assume a position comfortable for you and
test the suction, for the client (usually semi-Fowler’s or sitting upright with head
oropharyngeal hyperextended, unless contraindicated).
suctioning 11. Place a pulse oximeter on the client’s finger. Take a reading,
introduce the and leave the pulse oximeter in place.
catherter into the 12. Place a towel across the client’s chest.
posterior of the
mouth without 13. Perform hand hygiene. Put on a face shield if splashing is
likely.
applying suction,
you may need to 14. Connect one end of the connecting tubing to the suction
depress the machine, and place the other end in a convenient location near
tongue, apply the client. Turn on the suction device, and set the vacuum
suction while regulator to appropriate negative pressure (120–150 mm Hg).
Appropriate pressure may vary; check agency policy.
rotating and
remove the 15. If indicated, increase supplemental oxygen therapy to 100% or
catheter for as ordered by the physician. Encourage the client to breathe
deeply.
approximately 5 16. Preparation for all types of suctioning:
seconds, rinse A. Open the suction kit or catheter, using aseptic technique. If
catheter in sterile a sterile drape is available, place it across the client’s chest
water, encourage or on the overbed table. Do not allow the suction catheter to
client to take deep touch any nonsterile surfaces.
breaths and cough B. Unwrap or open a sterile basin and place it on the bedside
between suction, table. Fill it with about 100 mL of sterile normal saline
allow 20 seconds solution or water. Connect one end of connecting tubing to
between each suction machine. Place other end in convenient location
suction attempt. near client. Check that equipment is functioning properly
For by suctioning a small amount of water from basin.
nasopharyngeal C. Turn on suction device. Set regulator to appropriate
suctioning negative pressure: 100–150 mm Hg for adults.
introduce catheter 17. Suction airway.
medially into the
nostril about 13 A. Oropharyngeal suctioning:
cms without (1) Put on clean disposable glove to your dominant hand.
applying suction, Put on mask or face shield.
apply suction while (2) Attach the suction catheter to connecting tubing.
rotating and Check that equipment is functioning properly by
withdrawing the suctioning a small amount of water or normal saline
catheter for 5 from the basin.
seconds, rinse in (3) Remove oxygen mask, if present. Keep the oxygen
sterile water, allow mask near the client’s face. A nasal cannula may
client to rinse out remain in place (if present).
mouth, assess
client after each
suctioning and
after procedure.
(4) Insert the catheter into the client’s mouth. With
suction applied, move the catheter around the mouth,
including pharynx and gum line, until secretions are
cleared.
(5) Encourage the client to cough, and repeat suctioning
if needed. Replace oxygen mask, if used.
(6) Suction water from the basin through the catheter
until the catheter is cleared of secretions.
(7) Place the catheter in a clean, dry area for reuse, with
suction turned off, or within the client’s reach, with
suction on, if the client is capable of suctioning self.
B. Nasopharyngeal and nasotracheal suctioning:
(1) Increase supplemental oxygen therapy to 100% as
indicated or as ordered. Encourage client to breathe
deeply. Open the lubricant. Squeeze a small amount
onto the open sterile catheter package.
(2) Put a sterile glove on each hand, or put a nonsterile
glove on your nondominant hand and a sterile glove on
your dominant hand.
(3) Pick up the suction catheter with your dominant hand
without touching nonsterile surfaces. Pick up
connecting tubing with your nondominant hand. Secure
 the catheter to the tubing.
(4) Check that the equipment is functioning properly by
suctioning a small amount of normal saline solution
from the basin.
(5) Lightly coat the distal 6–8 cm of the catheter with
water-soluble lubricant.
(6) Remove the oxygen delivery device, if applicable, with
your nondominant hand. Without applying suction and
using your dominant thumb and forefinger, gently
insert the catheter into the client’s naris during
inhalation.
(7) Nasopharyngeal: Follow the natural course of the naris;
slightly slant the catheter downward and advance to the
back of the pharynx. In adults, insert the catheter about
16 cm; in older children, 8–12 cm; in infants and young
children, 4–8 cm. The rule of thumb is to insert the
catheter a distance from the tip of the nose (or mouth)
to the base of the earlobe.

(a) Apply intermittent suction for up to 10–15 seconds

by placing and releasing your nondominant thumb
over the catheter vent. Slowly withdraw the
catheter while rotating it back and forth between
your thumb and forefinger.

(9) Rinse the catheter and connecting tubing with normal

saline or water until cleared.
(10) Assess for need to repeat the suctioning procedure.
Allow adequate time (1–2 minutes) between suction
passes for ventilation and oxygenation. Ask the client
to breathe deeply and cough.
C. Artificial airway suctioning:
(1) Put on face shield.
(2) Put one sterile glove on each hand, or put a nonsterile
glove on your nondominant hand and a sterile glove
on your dominant hand.
(3) Pick up the suction catheter with your dominant hand
without touching nonsterile surfaces. Pick up the
connecting tubing with your nondominant hand.
Secure the catheter to the tubing.

(4) Check that equipment is functioning properly by

suctioning a small amount of saline from the basin.
(5) Hyperinflate or hyperoxygenate the client, or do both,
 before suctioning, using manual resuscitation Ambu-
bag connected to the oxygen source on the
mechanical ventilator. Some mechanical ventilators
have a button that, when pushed, delivers oxygen for
a few minutes and then resets to the previous value.
(6) If the client is receiving mechanical ventilation, open
swivel the adapter or, if necessary, remove the
oxygen or humidity delivery device with your
nondominant hand.
(7) Without applying suction, gently but quickly insert
the catheter, using your dominant thumb and
forefinger, into the artificial airway (it is best to time
catheter insertion with inspiration) until resistance is
met or the client coughs; then pull back 1 cm.
(8) Apply intermittent suction by placing and releasing
your nondominant thumb over the vent of the
catheter; slowly withdraw the catheter while rotating
it back and forth between your dominant thumb and
forefinger. Encourage the client to cough. Watch for
respiratory distress.
(9) If the client is receiving mechanical ventilation, close
the swivel adapter or replace the oxygen delivery
device.
(10) Encourage the client to breathe deeply, if able. Some
clients respond well to several manual breaths from
the mechanical ventilator or Ambu bag.
(11) Rinse the catheter and connecting tubing with normal
saline until clear. Use continuous suction.
(12) Assess the client’s cardiopulmonary _status. Repeat
steps 17C(5) through 17C(11) once or twice more to
clear secretions. Allow adequate time (at least 1 full
minute) between suction passes for ventilation and
reoxygenation. Perform oropharyngeal and
nasopharyngeal suctioning (Steps 17A and 17B).
After oropharyngeal and nasopharyngeal suction is
performed, the catheter is contaminated; do not
reinsert it into the endotracheal or tracheostomy tube.

18. Complete the procedure:

A. Disconnect the catheter from the connecting tubing. Roll
the catheter around the fingers of your dominant hand. Pull
the glove off inside out so that the catheter remains in the
glove. Pull off the other glove over the first glove in the
same way to contain contaminants. Discard gloves into an
appropriate receptacle. Turn off the suction device.
B. Remove the towel or drape, and discard it in an appropriate
receptacle.
 C. Reposition the client as indicated by the condition. Put on
clean gloves for the client’s personal care (e.g., oral
hygiene).
D. If indicated, readjust oxygen supply to the original level.
E. Discard the remainder of normal saline into an appropriate
receptacle. If the basin is disposable, discard into an
appropriate receptacle. If the basin is reusable, rinse and
place in soiled utility room.
F. Remove and discard the face shield, and perform hand
hygiene.
G. Place an unopened suction kit on the suction machine table
or at the head of bed, according to institution preference.
19. Compare the client’s vital signs and SpO2 saturation before and
after suctioning.
20. Ask the client whether breathing is easier and whether
congestion is decreased.
21. Observe airway secretions.

Care of Trachesostomy
(suctioning and
dressing change, trach B. Tracheostomy care:
tie change) (1) Observe for signs and symptoms of the need to
perform tracheostomy care:
- asses client to (a) Soiled or loose ties or dressing
determine need for
(b) Nonstable tube
suctioning, turn on
suction source to 80-120 (c) Excessive secretions
mm mercury, pour saline (2) Suction tracheostomy. Before removing gloves, remove
into tray, add catheter to soiled tracheostomy dressing and discard in a glove
sterile field, place sterile with the coiled catheter.
drape near the (3) While client is replenishing oxygen stores, prepare
tracheostomy, pick up the equipment on bedside table:
suction tubing with your (a) Open sterile tracheostomy kit. Open three 4 × 4
non dominant hand (now gauze packages, using aseptic technique, and pour
unsterile), attach the normal saline (NS) on one package and hydrogen
tubes and test the suction peroxide on another. Leave the third package dry.
ability, hyperoxygenate Open two packages of cotton-tipped swabs and
the client by encouraging pour NS on one package and hydrogen peroxide on
them to take several the other. Do not recap hydrogen peroxide and NS.
deep breaths, remove (b) Open the sterile tracheostomy package.
tracheostomy tubing and
(c) Unwrap the sterile basin and pour approximately
insert catheter without 0.5–2 cm of hydrogen peroxide into it.
suction, advance until
resistance is met or the (d) Open the small sterile brush package and place it
aseptically into the sterile basin.
client coughs, do not
suction for more than 15 (e) Prepare a length of twill tape long enough to go
seconds, encourage around the client’s neck two times, approximately
client to take slow deep 60–75 cm for an adult. Cut ends on the diagonal.
breaths while you rinse Lay aside in a dry area.
the catheter, repeat until (f) If using a commercially available tracheostomy
the airway is clear tube holder, open the package according to the
- dressing change: add manufacturer’s directions.
supplies to tray (4) Put on gloves. Keep your dominant hand sterile
aseptically, put on gloves, throughout the procedure.
remove old dressing with
(5) Remove the oxygen source from the kit. Apply the
forceps and place in oxygen source loosely over the tracheostomy if the
garbage bag, assess the client desaturates during the procedure.
wound, clean using one
gauze per swiping motion
and then discard it (clean
with two forceps, gauze (6) If a nondisposable inner cannula is used:
and saline), clean the (a) While touching only the outer aspect of the tube,
flange of the remove the inner cannula with your nondominant
tracheostomy tube with hand. Drop the inner cannula into the hydrogen
the large q-tips (pick up peroxide basin.
q-tips with forceps), dry (b) Place the tracheostomy collar or T tube and
the skin, place guaze ventilator oxygen source over or near the outer
dressing around the cannula. (Note: T tube and ventilator oxygen
tracheostomy. devices cannot be attached to all outer cannulas
- cuff deflation: semi when the inner cannula is removed.)
fowler’s position, put on (c) To prevent oxygen desaturation in affected clients,
gloves, assess client (you quickly pick up the inner cannula and use a small
may need to do brush to remove secretions from inside and outside
suctioning first), prepare the cannula.
equipment, place pad (d) Hold the inner cannula over the basin and rinse
across the client’s chest, with NS, using your nondominant hand to pour.
attach catheter to the
(e) Replace the inner cannula and secure the “locking”
suction source and set to mechanism. Reapply the ventilator or oxygen
120 mm of mercury, sources.
attach syringe to the pilot
(7) If a disposable inner cannula is used:
balloon port and withdraw
the air until it deflates, (a) Remove the cannula from the manufacturer’s
encourage client to cough packaging.
out secretions (remove (b) While touching only the outer aspect of the tube,
with oral suction withdraw the inner cannula and replace with the
catheter), to inflate the new cannula. Lock into position.
cuff auscultate the (c) Dispose of the contaminated cannula in an
trachea and fill the appropriate receptacle, and apply oxygen source.
balloon slowly (1 ml/sec) (8) Using hydrogen peroxide–prepared cotton-tipped
until you do not hear swabs and 4 × 4 gauze, clean the exposed outer
wind, once you can’t hear cannula surfaces and stoma under the faceplate,
it release some of the air extending 5–10 cm in all directions from the stoma.
so that you can just Clean in a circular motion from the stoma site
barely hear wind, outward, using your dominant hand to handle sterile
reassess client to ensure supplies.
breathing is not laboured, (9) Using NS-prepared cotton-tipped swabs and 4 × 4
check lung fields for air gauze, rinse the hydrogen peroxide from the
entry. tracheostomy tube and skin surfaces.
(10) Using dry 4 × 4 gauze, pat lightly at skin and exposed
outer cannula surfaces.
(11) Secure tracheostomy.
 (a) Tracheostomy tie method:
(a1) Instruct assistant, if available, to hold the
tracheostomy tube securely in place while ties are
cut.
(a2) Take the prepared tie and insert one end of the tie
through the faceplate eyelet, and pull ends even.
(a3) Slide both ends of the tie behind the client’s head
and around the neck to the other eyelet, and insert
one tie through the second eyelet.
(a4) Pull snugly.
(a5) Tie ends securely in a double square knot,
allowing space for only one finger in the tie.
(a6) Insert fresh tracheostomy dressing under the clean
ties and faceplate.
(b) Tracheostomy tube holder method:
(b1) While wearing gloves, maintain a secure hold
on the tracheostomy tube. This can be done with
an assistant or, when an assistant is not
available, by leaving the old tracheostomy tube
holder in place until the new device is secure.
(b2) Align strap under the client’s neck. Ensure that
Velcro attachments are positioned on either side
of the tracheostomy tube.
(b3) Place the narrow end of ties under and through
the faceplate eyelets. Pull the ends even, and
secure with Velcro closures.
(b4) Verify that there is space for only one loose or
two snug finger widths under the neck strap.
7. Position the client comfortably, and assess respiratory status.
8. Replace any oxygen delivery devices.
9. Remove and discard gloves. Replace the caps on the hydrogen
peroxide and normal saline. Perform hand hygiene.
10. Compare respiratory assessments made before and after the
procedure.
11. Observe depth and position of tubes.
12. Assess the security of the tape or commercial ET or ET tube
holder by tugging at the tube.
13. Assess the skin around the mouth and the oral mucosa (with ET
tube) and the tracheostomy stoma for drainage, pressure, and
signs of irritation.
Skill 39–2 Care of an Artificial Airway
Care of artificial airway

1. Perform cardiopulmonary assessment:

A. Auscultate lung sounds.
B. Assess condition and patency of airway and surrounding
tissues.
 C. Note type and size of tube, movement of tube, and cuff
size.
2. Explain the procedure to the client and family.
3. Position the client. Clients usually prefer to be lying down. A
client with a long-term, well-established tracheostomy may be
seated.
4. Place a towel across the client’s chest.
5. Perform hand hygiene.
6. Perform airway care:
A. Endotracheal (ET) tube care:
(1) Observe for signs and symptoms of the need to perform
care of the artificial airway:
(a) Soiled or loose tape
(b) Pressure sores on nares, lip, or corner of mouth
(c) Unstable tube
(d) Excessive secretions
(2) Identify factors that increase risk of complications from
ET tubes:
(a) Type and size of tube
(b) Movement of tube up and down trachea
(c) Cuff size
(d) Duration of placement
(3) Suction ET tube:
(a) Instruct the client not to bite or move the ET tube
with the tongue or pull on tubing; removal of tape
can be uncomfortable.
(b) Leave the Yankauer suction catheter connected to
the suction source.
(4) Prepare method to secure the ET tube (check agency
policy):
(a) Tape method: Cut a piece of tape long enough to go
completely around the client’s head, from naris to
naris, plus 15 cm: for an adult, about 30–60 cm.
Lay adhesive side up on the bedside table. Cut and
lay 8–16 cm of tape, adhesive side down, in the
centre of the long strip to prevent the tape from
sticking to the client’s hair.
(b) Commercially available endotracheal tube holder:
Open the package per manufacturer’s instructions.
Set the device aside with the head guard in place
and the Velcro strips open.
(5) Put on gloves, and instruct an assistant to put on a pair
of gloves and hold the ET tube firmly at the client’s
lips. Note the number marking on the ET tube at the
gum line.
(6) Remove old tape or device:
 (a) Tape: Carefully remove tape from the ET tube and
the client’s face. If the tape is difficult to remove,
moisten it with water or adhesive tape remover.
Discard tape in an appropriate receptacle if nearby.
If not, place soiled tape on the bedside table or on
the distant end of the towel.
(b) Commercially available device: Remove Velcro
strips from the ET tube, and remove the ET tube
holder from the client.
(7) Use adhesive remover swab to remove excess
secretions or adhesive left on the client’s face.
(8) Remove oral airway or bite block, if present.
(9) Clean the mouth, gums, and teeth opposite the ET
tube with mouthwash solution and 4 × 4 gauze,
sponge-tipped applicators, or saline swabs. Brush
teeth as indicated. If necessary, administer
oropharyngeal suctioning with a Yankauer catheter.
(10) Note “cm” ET tube marking at the lips or gums. With
the help of the assistant, move the ET tube to the
opposite side or centre of the mouth. Do not change
tube depth.
(11) Repeat oral cleaning on the opposite side of the
mouth.
(12) Clean the face and neck with a soapy washcloth; rinse
and dry. Shave a male client as necessary.

(13) Use a small amount of skin protectant or liquid

adhesive on a clean 2 × 2 gauze, and dot on the upper
lip (with oral ET tube) or across the nose (with nasal
ET tube) and from cheeks to ear. Allow tincture to
dry completely.
(14) Secure ET tube.
(a) Tube method:
(a1) Slip tape under the client’s head and neck,
adhesive side up. Do not twist the tape or
catch hair. Do not allow tape to stick to itself.
It helps to stick tape gently to the tongue
blade, which serves as a guide as the tape is
passed behind the client’s head. Centre tape
so that double-faced tape extends around the
back of the neck from ear to ear.
(a2) On one side of the client’s face, secure tape
from ear to naris (with nasal ET tube) or to
the edge of the mouth (with oral ET tube).
Tear remaining tape in half lengthwise,
forming two pieces that are 1–2 cm wide.
Secure the bottom half of the tape across the
upper lip (with oral ET tube) or across the top
of the nose (with nasal ET tube). Wrap the
top half of tape around the tube.
 (a3) Gently pull the other side of tape firmly to
pick up slack, and secure to the remaining
side of the face. Have the assistant release
hold when the tube is secure. You may want
the assistant to help reinsert the oral airway.
(b) Commercially available device:
(b1) Place the ET tube through the opening
designed to secure the ET tube. Ensure that
the pilot balloon to the ET tube is accessible.
(b2) Place the Velcro strips of the ET holder under
the client at the occipital region of the head.
(b3) Verify that the ET tube is at the established
position, using the lip or gum line as a guide.
(b4) Secure the Velcro strips at the base of the
client’s head. Leave 1 cm slack in the strips.
(b5) Verify that the tube is secure and that it does
not move forward from the client’s mouth or
backward down into the client’s throat.
Ensure that there are no pressure areas on the
oral mucosa or occipital region of the head.

(15) Clean the oral airway in warm, soapy water, and rinse
well. Hydrogen peroxide can aid in removal of
crusted secretions. Shake excess water from the oral
airway.
(16) For an unconscious client, reinsert the oral airway
without pushing the tongue into the oropharynx.
- Does the client look comfortable? Inquire about pain,
Care of chest drainage is the head of the bed elevated? Inspect insertion site,
systems: is the dressing intact? Check for air leaks, palpate the
- Drsg on chest tube surrounding tissue, inquire about pain at the site,
- I/O on chest tube check all tube connections and tubing
- Milking the tube involves pinching the tube and
releasing (this may dislodge blockage)
- Drainage system should be below the lungs (i.e. on
the floor), the amount of drainage should decrease
with time, notify a physician if drainage exceeds 100
mL/h, if there is a sudden increase in amount, or if the
drainage changes from clear to sanguineous.
- Water seal is to be set by the manufacturers
recommendations, if there is a constant bubble in the
water seal then there is a leak, pinch off the tubing to
the chest tube, if the bubbling persists then you know
the airleak is in the drainage system
- Temporary water seal: if the tubing is disconnect4ed
then put the end of the chest tube into normal saline
water to act as a water seal until new tubing can be
set up
- Do not clamp, if the suction is off, the drainage system
must be disconnected from the suction outlet and left
 open to the atmospheric air.
- Change drainage system: pour sterile water into the
suction chamber, the amount of suction exerted on the
pleural cavity is determined by the height of the water
in the suction chamber, fill the water to the level
ordered by the physician (usually 20 cms), or set the
suction gauge on the dry suction system, place the
system below the client, connect the chest tube: clamp
chest tube, disconnect the old chest tube and connect
the new one, release the clamp and tape the
connection

Use of manual
resuscitator ( Ambu-bag)

Neurovital signs and

documentation

PASS ______________________

ATTEMPT #2 ________________

ATTEMPT #3 ________________
INSTRUCTOR:_____________________

Skill 40–4 Changing a Peripheral Intravenous Dressing

1. Determine when dressing was last changed. Many institutions

require that the nurse record the date and time on the dressing
when the device is first placed.
2. Perform hand hygiene. Observe the present dressing for
moisture and intactness.
3. Observe the intravenous (IV) system for proper functioning.
Palpate the catheter site through the intact dressing for
inflammation or subjective complaints of pain or burning
sensation.
4. Inspect the exposed catheter site for swelling or blanching.
5. Assess the client’s understanding of the need for continued IV
infusion.
6. Explain procedure and purpose to the client and family. Explain
that the affected extremity must be held still and how long the
procedure will take.
7. Put on disposable gloves.
 8. Remove tape, gauze, or transparent dressing from the old
dressing, one layer at a time, leaving tape (if present) that
secures the IV needle in place. Be cautious to prevent the
catheter tubing from becoming tangled between two layers of
dressing. When removing transparent dressing, hold the
catheter hub and tubing with your nondominant hand.
9. Observe the insertion site for signs and symptoms of infection
(redness, swelling, and exudate). If they are present, remove the
catheter and insert a new IV line in another site.
10. If infiltration, phlebitis, or clot occurs, or if otherwise ordered
by physician, stop infusion and discontinue IV therapy. Restart
new IV line if continued therapy is necessary. Place a moist,
warm compress over an area of phlebitis.
11. If IV fluid is infusing properly, gently remove tape securing the
catheter. Stabilize the needle or catheter with one hand. Use
adhesive remover to cleanse skin and remove adhesive residue,
if needed.
12. Stabilize the catheter at all times with one finger over the
catheter until tape or dressing is replaced.

13. Use circular motion, cleanse the peripheral IV insertion site

with an antiseptic swab, starting at the insertion site and
working outward, creating concentric circles. Allow swab
solution to air-dry completely.
14. Apply new transparent or gauze dressing.
15. Remove and discard gloves.
16. Anchor IV tubing with additional pieces of tape. When using
transparent polyurethane dressing, minimize the tape placed
over dressing.
17. Write insertion date, date and time of dressing change, size and
gauge of catheter, and your initials directly on dressing. Apply
arm board, commercial housing device, or both if the site is
affected by joint motion.
18. Discard used equipment, and perform hand hygiene.
19. Observe functioning and patency of the IV system in response
to changing dressing.
20. Monitor the client’s body temperature.

Skill 44–2 Inserting a Straight or In-Dwelling Catheter

1. Review the client’s medical record, including physician’s order

and nurses’ notes.
2. Close bedside curtain or door.
3. Assess the status of the client:
A. Urinary status: Ask the client when he or she last voided, or
check intake and output flow sheet, or palpate bladder
 B. Level of awareness or developmental stage
C. Mobility and physical limitations of the client
D. The client’s gender and age
E. Bladder distension
F. Perineum, for erythema, drainage, and odour: Perform hand
hygiene, put on clean gloves, and inspect perineum
G. Any pathological condition that may impair passage of
catheter (e.g., enlarged prostate in men)
H. Allergies
4. Assess the client’s knowledge of the purpose of catheterization.
5. Explain the procedure to the client.
6. Arrange for extra nursing assistance if necessary.
7. Perform hand hygiene.
8. Raise the bed to an appropriate working height.
9. Facing the client, stand on the left side of the bed if you are
right-handed (on the right side if you are left-handed). Clear the
bedside table, and arrange equipment.
10. Raise the side rail on the opposite side of the bed, and put the
side rail down on the working side.
11. Place a waterproof pad under the client.
12. Position the client.
A. Female client:
(1) Assist the client to the dorsal recumbent position. Ask
the client to relax her thighs so that the hips can be
rotated externally.

(2) Assist the client to a side-lying (Sims’) position with

the upper leg flexed at the hip if the client is unable to
assume the dorsal recumbent position. If this position is
used, you must take extra precautions to cover the
rectal area with a drape to reduce chance of cross-
contamination.
B. Male client:
(1) Assist the client to a supine position with thighs
slightly abducted.
13. Drape client:
A. Female client:
(1) Drape with a bath blanket. Place the blanket in a
diamond shape over the client, with one corner at the
client’s midsection, side corners over each thigh and
the abdomen, and the last corner over the perineum.
B. Male client:
(1) Drape the client’s upper trunk with a bath blanket and
cover the lower extremities with bedsheets so that only
 genitalia are exposed.
14. Wearing disposable gloves, wash the perineal area with soap
and water as needed; dry thoroughly. Remove and discard
gloves; perform hand hygiene.
15. Position a lamp to illuminate the perineal area. (If you use a
flashlight, have an assistant hold it.)
16. Open the package containing the drainage system. Place the
drainage bag over the edge of the bottom bed frame, and bring
the drainage tube up between side rail and mattress.
17. Open the catheterization kit according to directions, keeping the
bottom of the container sterile.
18. Place the plastic bag that contained the kit within reach of the
work area to use as a waterproof bag in which used supplies can
be disposed.
19. Put on sterile gloves.
20. Organize supplies on a sterile field. Open the inner sterile
package containing the catheter. Pour sterile antiseptic solution
into the correct compartment containing sterile cotton balls.
Open the packet containing lubricant. Remove the specimen
container (the lid should be placed loosely on top) and the
prefilled syringe from the collection compartment of the tray,
and set them aside on the sterile field.
21. Before inserting an in-dwelling catheter, test the balloon by
injecting fluid from the prefilled syringe into the balloon port.

22. Lubricate 2.5–5 cm of the catheter for female clients and 12.5–
17.5 cm for male clients.
23. Apply the sterile drape:
A. Female client:
(1) Allow the top edge of the drape to form a cuff over
both gloved hands. Place the drape on the bed between
the client’s thighs. Slip the cuffed edge just under the
client’s buttocks, taking care not to touch the
contaminated surface with gloves.
(2) Pick up the fenestrated sterile drape and allow it to
unfold without touching any unsterile objects. Apply
the drape over the client’s perineum, exposing labia,
taking care not to touch the contaminated surface with
gloves.
B. Male client:
(1) Two methods are used for draping, depending on
preference.
First method: Apply the drape over the thighs and under the
penis without completely opening fenestrated drape.
Second method: Apply the drape over the thighs just below
the penis. Pick up the fenestrated sterile drape, allow it to
unfold without touching any unsterile objects, and drape it
over the penis, with the fenestrated slit resting over the
 penis.
24. Place the sterile tray and contents on the sterile drape. Open the
specimen container.
25. Cleanse the urethral meatus.
A. Female client:
(1) With your nondominant hand, carefully retract the labia
to fully expose the urethral meatus. Maintain position
of your nondominant hand throughout the procedure.
(2) Holding forceps in your sterile dominant hand, pick up
a cotton ball saturated with antiseptic solution and
clean the client’s perineal area, wiping from clitoris
toward anus (front to back). Using a new cotton ball for
each area, wipe along the far labial fold, the near labial
fold, and directly over the centre of the urethral meatus.

B. Male client:
(1) If the client is not circumcised, retract the foreskin with
your nondominant hand. Grasp the penis at the shaft,
just below the glans. Retract the urethral meatus
between your thumb and forefinger. Maintain your
nondominant hand in this position throughout the
procedure.
(2) With your sterile dominant hand, use forceps to pick up
a cotton ball saturated with antiseptic solution, and
clean the penis. Move the cotton ball in circular motion
from the urethral meatus down to the base of the glans.
Repeat cleansing three more times, using a clean cotton
ball each time.
26. Pick up the catheter with your gloved dominant hand, 7.5–10
cm from the catheter tip. Hold the end of the catheter loosely
coiled in the palm of your dominant hand. (Optional: Grasp the
catheter with forceps.)
27. Insert the catheter.
A. Female client:
(1) Ask the client to bear down gently as if to void urine,
and slowly insert the catheter through the urethral
meatus.
(2) Advance the catheter a total of 5–7.5 cm in an adult or
until urine flows out the catheter’s end. When urine
appears, advance the catheter another 2.5–5 cm. Do not
use force against resistance.
(3) Release the labia and hold the catheter securely with
 your nondominant hand. Slowly inflate the balloon if
the in-dwelling catheter is being used.
B. Male client:
(1) Lift the client’s penis to position perpendicular to the
client’s body, and apply light traction.
(2) Ask the client to bear down gently as if to void urine,
and slowly insert the catheter through the urethral
meatus.
(3) Advance the catheter 17–22.5 cm (7–9 inches) in an
adult or until urine flows out the catheter’s end. If
resistance is felt, withdraw the catheter; do not force it
through the urethra. When urine appears, advance the
catheter another 2.5–5 cm. Do not use force against
resistance.

(4) Lower the client’s penis and hold the catheter securely
in your nondominant hand. Place the end of the catheter
in the urine tray. Inflate the balloon if an in-dwelling
catheter is being used.
(5) Reduce (or reposition) the foreskin.
28. Collect the urine specimen as needed. Fill the specimen cup or
jar to the desired level (20–30 mL) by holding the end of the
catheter over the cup with your dominant hand.
29. Allow the client’s bladder to empty fully (about 800–1000 mL)
unless institution policy restricts the maximal volume of urine
to drain with each catheterization. Check institution policy
before beginning catheterization.
30. Inflate the balloon fully per manufacturer’s recommendation,
and then release the catheter with your nondominant hand and
pull gently.
31. Attach the end of the in-dwelling catheter to the collecting tube
of the drainage system. The drainage bag must be below the
level of the bladder. Attach the bag to the bed frame; do not
place the bag on the bed’s side rails.
32. Anchor the catheter:
A. Female client:
(1) Secure the catheter tubing to the client’s inner thigh or
abdomen with a strip of nonallergenic tape (or
multipurpose tube holders with a Velcro strap). Allow
for slack so that movement of the thigh does not create
tension on the catheter.
B. Male client:
(1) Secure the catheter tubing to the top of the thigh or
lower abdomen (with the penis directed toward the
chest). Allow for slack so that movement foes not
create tension on the catheter.
33. Assist the client to a comfortable position. Wash and dry the
 perineal area as needed.
34. Remove gloves and dispose of equipment, drapes, and urine in
proper receptacles.
35. Perform hand hygiene.
36. Palpate the client’s bladder.
37. Ask whether the client is comfortable.
38. Observe the character and amount of urine in the drainage
system.
39. Ensure that no urine is leaking from the catheter or tubing
connections.
40. Record and report catheterization, characteristics and amount of
urine, specimen collection (if performed), and client’s response
to procedure and teaching concepts.
41. Initiate intake and output records.

Skill 44–4 Closed and Open Catheter Irrigation

1. Assess the physician’s order for type of irrigation and irrigation

solution to use.
2. Assess the colour of urine and the presence of mucus or
sediment.
3. Determine the type of catheter in place:
A. Triple-lumen (one lumen to inflate the balloon, one to
instill irrigation solution, one to allow outflow of urine)
B. Double-lumen (one lumen to inflate the balloon, one to
allow outflow of urine)
4. Determine the patency of the drainage tubing.
5. Assess the amount of urine in the drainage bag (you may want
to empty the drainage bag before irrigation).
6. Explain the procedure and purpose to the client.
7. Perform hand hygiene, and put on clean disposable gloves for
closed methods.
8. Provide privacy by pulling bed curtains closed. Fold back
covers so that the catheter is exposed. Cover the client’s upper
torso with the bath blanket.
9. Assess the lower abdomen for bladder distension.
10. Position the client in the dorsal recumbent or supine position.
11. Closed intermittent irrigation (with double-lumen catheter):
A. Prepare prescribed solution in a sterile graduated cup.
B. Draw sterile solution into a syringe, using aseptic
technique.
C. Clamp in-dwelling catheter just distal to soft injection
(specimen) port.
D. Cleanse injection port with antiseptic swab (same port used
 for specimen collection).
E. Insert the syringe at a 30-degree angle toward the bladder.
F. Slowly inject fluid into the catheter and bladder.

G. Withdraw the syringe, remove the clamp, and allow

solution to drain into the drainage bag. If ordered by the
physician, keep the bag clamped to allow solution to remain
in the bladder for a short time (20–30 minutes).
12. Closed continuous irrigation (with triple-lumen catheter):
A. Using aseptic technique, insert the tip of the sterile
irrigation tubing into the bag of sterile irrigating solution.
B. Close the clamp on the tubing and hang the bag of solution
on the intravenous (IV) pole.
C. Open the clamp and allow solution to flow through tubing,
keeping the end of tubing sterile. Close the clamp.
D. Wipe off the irrigation port of the triple-lumen catheter, or
attach a sterile Y connector to the double-lumen catheter
and then attach to irrigation tubing.
E. Be sure that the drainage bag and tubing are securely
connected to drainage port of the triple-lumen catheter or
other arm of the Y connector.
F. For intermittent flow, clamp the tubing on the drainage
system, open the clamp on the irrigation tubing, and allow
the prescribed amount of fluid to enter the bladder. Close
the irrigation clamp and then open the drainage tubing
clamp. (Optional: Leave the clamp closed for 20–30
minutes if ordered.)
G. For continuous drainage, calculate the drip rate and adjust
the clamp on the irrigation tubing accordingly. Ensure that
the clamp on the drainage tubing is open, and check the
volume of drainage in the drainage bag. Ensure that
drainage tubing is patent, and avoid kinks.
13. Open irrigation (with double-lumen catheter):
A. Open the sterile irrigation tray, establish a sterile field, pour
the required volume of sterile solution into the sterile
container, and replace the cap on the large container of
solution.
B. Put on sterile gloves.
C. Position the sterile waterproof drape under the catheter.
D. Aspirate 30 mL of solution into the sterile irrigating
syringe.
E. Move the sterile collection close to the client’s thighs.
F. Disconnect the catheter from the drainage tubing, allowing
urine from the catheter to flow into the collection basin.
Allow urine in tubing to flow into the drainage bag. Cover
the end of tubing with a sterile protective cap. Position
 tubing in a safe place.
G. Insert the tip of the syringe into the catheter lumen, and
gently instill solution.
H. Withdraw the syringe, lower the catheter, and allow
solution to drain into the basin. Repeat instillation until the
prescribed solution has been used or until drainage is clear,
depending on the purpose of irrigation.
I. If solution does not return, have the client turn onto the side
facing you. If changing position does not help, reinsert the
syringe and gently aspirate solution.
J. After irrigation is complete, remove the protector cap from
the tubing, cleanse the end with an alcohol swab (or the
agency’s recommended solution), and re-establish the
drainage system.
14. Re-anchor the catheter to the client with tape or an elastic tube
holder.
15. Assist the client to a comfortable position.
16. Lower the bed to the lowest position. Put the side rails up if
appropriate.
17. Dispose of contaminated supplies, remove gloves, and perform
hand hygiene.
18. Calculate the amount of fluid used to irrigate the bladder, and
subtract from total output.
19. Assess characteristics of output: viscosity, colour, and presence
of matter (e.g., sediment, clots, blood).
SKILL PERFORMANCE CHECKLIST

Skill 39–3 Care of Clients with Chest Tubes

1. Perform hand hygiene and assess client: for respiratory distress

and chest pain, breath sounds over affected lung area, and vital
signs.
A. Pulmonary status: Assess for respiratory distress, chest
pain, breath sounds over affected lung area, and stable vital
signs. Signs and symptoms of increased respiratory distress
or chest pain include decreased breath sounds over the
affected and nonaffected lungs, marked cyanosis,
asymmetrical chest movements, presence of subcutaneous
emphysema around tube insertion site or neck, hypotension,
and tachycardia.
B. Measure vital signs and SpO2.
C. Pain: If possible, ask the client to rate the level of pain on a
scale of 0 to 10.
2. Observe the following:
A. Chest tube dressing and site surrounding tube insertion
B. Tubing, for kinks, dependent loops, or clots
C. Chest drainage system, which should be upright and below
 level of tube insertion
3. Provide two shodded hemostats or approved clamps for each
chest tube, and attach them to the top of the client’s bed with
adhesive tape. Chest tubes are clamped only under specific
circumstances per physician order or nursing policy and
procedure:
A. To assess air leak
B. To quickly empty or change disposable systems; performed
by a nurse who has received education in the procedure
C. If the drainage tubing is accidentally disconnected from the
drainage collection device or if the device is damaged
D. To assess whether the client is ready to have the chest tube
removed (which is done by physician’s order); the client is
monitored for recurrent pneumothorax

4. Position client in one of the following ways:

A. Semi-Fowler’s position to evacuate air (pneumothorax)
B. High-Fowler’s position to drain fluid (hemothorax,
effusion)
5. Maintain the tube connection between the chest and drainage
tubes; ensure that it is intact and taped.
A. The water-sealed vent must be without occlusion.
B. The suction-control chamber vent must be without
occlusion when suction is used.
6. Avoid excess tubing; the tubing should be laid horizontally
across the client’s bed or chair before dropping vertically into
the drainage bottle. If the client is in a chair and the tubing is
coiled, lift the tubing every 15 minutes to promote drainage.
7. Adjust the tubing to hang in a straight line from the top of the
mattress to the drainage chamber. If the chest tube is draining
fluid, indicate time (e.g., 0900 hours) that drainage began on
the drainage bottle’s adhesive tape or on the write-on surface of
the disposable commercial system. Strip or milk chest tube only
if indicated.
8. Perform hand hygiene.
9. Evaluate:
A. Vital signs and pulse oximetry as ordered or if client’s
condition changes.
B. Chest tube dressing.
C. Tubing: It should be free of kinks and dependent loops.
D. Chest drainage system: It should be upright and below the
level of tube insertion. Note the presence of clots or debris
in tubing.
E. Water seal for fluctuations with the client’s inspiration and
 expiration.
(1) Waterless system: diagnostic indicator for fluctuations
with client’s inspirations and expirations
(2) Water-seal system: bubbling in the water-seal chamber
(3) Water-seal system: bubbling in the suction-control
chamber (when suction is used)
F. Waterless system: Bubbling is diagnostic indicator.
G. Type and amount of fluid drainage: Note colour and
amount of drainage, client’s vital signs, and skin colour.
The normal amount of drainage is as follows:

(1) In the adult: <50–200 mL/hour immediately after

surgery in a mediastinal chest tube; approximately 500
mL in the first 24 hours.
(2) Between 100 and 300 mL of fluid may drain in a
pleural chest tube in an adult during the first 3 hours
after insertion. This rate will decrease after 2 hours;
500–1000 mL can be expected in the first 24 hours.
Drainage is grossly bloody during the first several
hours after surgery and then changes to serous.
Remember that a sudden gush of drainage may be
retained blood and not active bleeding. This increase in
drainage can result from client’s position changes.
H. Waterless system: The suction control (float ball) indicates the
amount of suction that the client’s intrapleural space is
receiving.
I. Observe the client for decreased respiratory distress and chest
pain; auscultate lung sounds over the affected area, and monitor
SpO2.
J. Pain: Ask the client to evaluate pain on a level of 0–10.