Chronological Steps Of A Procedure Flashcards
What are the key steps in inserting Large Bore NGT?
1) Perform hand hygiene & apply CLEAN GLOVES
(no need for sterile gloves)
2)Place the client in HIGH FOWLER’S position
3) Assess nares & oral cavity & select naris
4) Measure & MARK THE TUBE
5) Curve 4-6” tube around the index finger & release
6) LUBRICATE end of the tube w/ water soluble-jelly
7) INSTRUCT CLIENT TO EXTEND NECK BACK
SLIGHTLY
8) GENTLY INSERT TUBE JUST PAST NASOPHARYNX
aiming tip downward
9) Rotate tube slightly if resistance is met, allowing rest
periods for the client.
10) continue insertion until just above oropharynx
12) ASK CLIENT TO FLEX HEAD FORWARD and
SWALLOW
13) ADVANCE TUBE TO MARK POINT
14) VERIFY TUBE PLACEMENT & ANCHOR
Use agency policy to verify placement using ABDOMINAL X-RAY & by anchoring tube in place.
Other measures to verify NGT placement?
Aspirating gastric content
Testing the PH (should be 5.5 & below)
Auscultation of inserted air
What are the key steps in suctioning an EndoTracheal Tube?
1) Perform hand hygiene & don clean gloves
2) Suction the oropharynx & PERFORM ORAL CARE
3) Ensure that the system is connected to appropriate
wall suction ( < 120 mmHg)
4) HYPEROXYGENATE the lungs (100% FIO2)
5) Advance the catheter into the trachea just until
resistance is met (level of carina)
DO NOT SUCTION while advancing the catheter
6) GENTLY REMOVE THE CATHETER WHILE
SUCTIONING & ROTATING IT.
Do not suction for more than 10 SECONDS.
What is the purpose of Tracheal Suctioning through an Endotracheal Tube?
To clear retained bronchial secretions & increases ventilatory efficacy with strict asepsis
How do you asses to ensure proper shoulder sling fit?
1) ELBOW IS FLEXED AT 90 DEGREES
(to support forearm, prevent swelling, relieve
shoulder pressure)
2) HAND IS HELD SLIGHTLY ABOVE THE LEVEL OF
THE ELBOW
(to prevent venous pooling & edema)
3) BOTTOM OF THE SLING ENDS IN THE MIDDLE OF
PALM WITH THE FINGERS VISIBLE
(to be able to assess circulation, sensation &
movement)
4) SLING SUPPORTS THE WRIST JOINT with the thumb
facing upward/inward towards the body
(to maintain proper alignment)
( Skin irritation, which can occur under the sling &
around the neck if the strap is too tight)
The Pediatric nurse is preparing to administer an acetamenophen suppository to an 11-month old with pyrexia. Which actions are appropriate?
Below 3 years old: Supine position with knees & feet raised, push suppository with the FIFTH FINGER
Over 3 years old: Side-lying (Sim’s) position with knees flexed, push suppository with the INDEX FINGER
How do you reduce stress/anxiety to children when administering suppositories?
AGE-APPROPRIATE EXPLANATIONS/DISTRACTIONS are implemented
Toddler/Infants: may benefit from distraction from A TOY
Preschoolers/Older children: instructed to TAKE A DEEP
BREATHS or COUNT during the procedure
What are the Basic Steps in administering SUPPOSITORIES?
1) APPLY CLEAN GLOVES & POSITION CLIENT appropriately based on age & size
2) LUBRICATE the tip of the suppository with a WATER-SOLUBLE JELLY. Petroleum based product could reduce absorption
3) INSERT the suppository past the internal sphincter
using the 5TH FINGER ( >3 yo. to prevent injury to
the colon/sphincter)
4) ANGLE suppository & GUIDE IT ALONG REECTAL
WALL ( should remain in contact with rectal mucosa)
5) HOLD BUTTOCKS TOGETHER for several minutes
If bowel occurs within 10-30 mins., observe for the
presence of suppository
What are the steps in removing the CATHETER?
1) Perform hand hygiene
2) Provide privacy and explain procedure to the client
3) Don clean gloves
4) Put a water proof pad underneath the client
5) Remove adhesive tape or device anchoring the catheter
6) Loosen the syringe plunger and connect empty syringe hub into the inflation port
7) Deflate the balloon by allowing the water to flow back naturally, removing all 10 ml/applicable amount. If the water does not flow back naturally, use only gentle aspiration
8) Remove catheter gently and slowly. Inspect and make sure it is intact and fragment were not left in the client.
9) If resistance is met, stop and consult urologist for removal
10) Empty and measure urine before discarding the catheter and urine bag in the biohazard bin or according to hospital policy
11) Remove gloves and perform hand hygiene
How to initiate IV Therapy
1) PERFORM HAND HYGIENE
PREPARE EQUIPMENT (Open IV tray, prime tubing with prescribed solution for infusion, set IV pump if indicated, prepare tape, open the over-the needle catheter (ONC) with safety device)
3) DON CLEAN GLOVES
4) iDENTIFY A POSSIBLE VENIPUNCTURE SITE
5) APPLY A TORNIQUET, ensuring tight enough to impede venous return but not too tight to occlude the artery
6) Select a veni puncture site after palpating the vein. Ask client to close-oepn the hand several times to promote vein distention
7) CLEAN THE SITE with clorhexidine, alcohol or povidone iodine, either back and forth or circular motion from insertion site to outward area (clean to dirty direction)
8) STRETCH THE SKIN TAUT using non-dominant hand to stabilize the vein
9) INSERT THE IV ONC bevel up to 10-30 degree angle and watch for blood back flow as the catheter enters the vein lumen, advancing 1/4 inch into the vein to release the stylet. On visualization of the blood return, lower the ONC almost parallel with the skin and thread the plastic cannula completely into the vein to the insertion site. Use push-tab safety device to advance the catheter.
10) Apply firm but gentlepressure about 1 1/4 above the catheter tip, release the torniquet, and retract the stylet from the ONC
11) On removal, guide the protective guard over the stylet for safety and feel for a click as the device is lock. Never try to recap a stylet
12) Attached a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing using sterile technique. Dispose stylet in the sharps container
How do you COLLECT a CLEAN CATCH URINE SPECIMEN in females
1) Perform HAND HYGIENE and REMOVES CONTAINER LID with sterile side placed upwards
2) SPREAD LABIA USING index finger and THUMB of NON-DOMINANT hand
CLEANSES VULVA from FRONT to BACK with single use antiseptic towelettes
3) INITIATE URINARY STREAM before PASSING CONTAINER INTO THE STREAM for collection
4) REMOVE specimen container from stream before stopping urinary flow
