12/31/13

Setting up Disposable Chest Drainage Systems

Setting up Disposable Chest Drainage Systems

Equipment
■ 2 disposable chest drainage units (CDU).
■ Chest tube insertion kit (common tube size for adults is 36 Fr; kit should contain povidone-iodine, local anesthetic, syringe, needles, drapes, scalpel, suture).
■ 5-in-1 or Y-connector for two chest tubes, if not contained in insertion kit.
■ 2 rubber-tipped hemostats.
■ Sterile gloves, masks, and sterile gowns.
■ Sterile 4 in. 4 in. gauze dressings.
■ Sterile, precut drain dressings.
■ Petroleum-based gauze dressings.
■ Large drainage dressings (e.g., ABD).
■ 2-in. silk tape.
■ 1-in. silk tape or nylon banding system for securing tube connections.
■ For a water-seal system, you also need sterile water.

Assessment
■ Ensure that the patient has venous access.
■ Assess:
■ VS.
■ Level of consciousness, orientation, responsiveness, anxiety, and restlessness.
■ Patient’s knowledge of chest tube therapy.
■ Cardiac and respiratory status, including rate, depth, and rhythm.
■ Breath sounds.
■ Skin color.
■ Pulse oximetry.
■ ABG results.

Post-Procedure Reassessment
■ Evaluate the patient’s tolerance to the chest tube insertion.
■ Determine whether the patient’s respiratory status has changed after tube insertion.
■ Auscultate breath sounds every 2 hours.
■ Check type, color, and amount of chest drainage every 15 minutes for the first 2 hours, and then check as prescribed (at least every 4 hours).
■ Assess for crepitus and drainage around the chest tube insertion site.
■ Check the disposable chest drainage system for air leaks.
■ Monitor I&O every 8 hours.
■ Check laboratory values to evaluate blood loss and oxygenation.

Key Points
■ Obtain and prepare the prescribed drainage system.
■ Position the patient according to the indicated insertion site.
■ Open the chest tube insertion tray and set up the sterile field.
■ Don mask, gown, and sterile gloves and organize the supplies you will need for dressing the insertion site.
■ As soon as the chest tube is inserted, attach it to the drainage system.
■ Turn on the wall (or other) suction source (usually –80 mm H2O).
■ Set the prescribed CDU suction level (usually –20 cm H2O).
■ After the clinician sutures the chest tube in place, don a clean pair of sterile gloves.
■ Be Safe! Using sterile technique, wrap petroleum gauze around the chest tube at the insertion site, and dress the site with two precut sterile drain dressings covered by a large drainage dressing (e.g., ABD).
■ Be Safe! Apply an occlusive dressing over the insertion site (e.g., with 2-inch silk tape); cover the dressing completely. Date, time, and initial the dressing.
■ Be Safe! Using the spiral taping technique, wrap 1-inch silk tape around the connections. Wrap from top to bottom and bottom to top. (Or use locking connections, if furnished with the CDU).
■ With an 8-inch-long piece of 2-inch tape, secure the top end of the drainage tube to the chest tube dressing.
■ Make sure the tubing lies with no kinks and no dependent areas, in a straight line to the CDU.
■ Prepare the patient for a portable chest x-ray exam.
■ Be Safe! Keep emergency supplies at the bedside in the event of tube dislodgement or system failure (2 rubber-tipped clamps, petroleum gauze dressing, and spare disposable CDU).
■ Be Safe! Maintain the chest tube and drainage system by preventing kinks, ensuring patency of the air vent, and keeping the system below the level of the chest tube.
■ Be Safe! Keep the head of the bed always elevated to at least 30°.

Documentation
■ Document:
■ Assessment findings before, during, and after chest tube insertion (e.g., VS, breath sounds, cardiac status, pulse oximetry).
■ Date and time of the chest tube insertion.
■ Name of the clinician who performed the procedure.
■ Location of the insertion site, size of the chest tube, type of drainage system, and amount of suction applied, if any.
■ Any medications the patient received during the procedure.
■ Color and amount of drainage.
■ Patient’s tolerance to the procedure.
■ Presence of subcutaneous emphysema or air leak, if any.
■ Complications and any interventions preformed as a result of the complications.
■ Chest x-ray findings.
■ Record chest tube output on the I&O portion of the flowsheet (in most agencies).

CDU set up and in place
Precut drain dressing
Spiral taping the connector
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Caring for Patients Requiring Mechanical Ventilation

Caring for Patients Requiring Mechanical Ventilation

Equipment
■ 2 oxygen sources.
■ Air source that provides 50 psi.
■ Mechanical ventilator.
■ Resuscitation bag with oxygen connection tubing.
■ Humidification device.
■ Ventilator tubing, connectors, and adaptors.
■ Condensation collection device.
■ Pulse oximetry device.
■ Procedure gloves, protective gown, and eye covering.
■ Sterile gloves and suction equipment, if you will perform suctioning.
■ Suction equipment.
■ Sterile water for the humidifier.
■ Inline thermometer.

Assessment
■ Review the health record to make sure that mechanical ventilation is included in the options outlined in the patient’s advance directive.
■ Assess the patient’s understanding of mechanical ventilation therapy, if possible.
■ Assess:
■ Respiratory status, including rate, depth, and rhythm.
■ Breath sounds.
■ Color.
■ Pulse oximetry results.
■ Be Smart! Blood may be drawn for a baseline ABG analysis.

Post-Procedure Reassessment
■ After mechanical ventilation is instituted, assess for chest expansion and auscultate bilateral breath sounds.
■ Auscultate breath sounds every 2 to 4 hours, according to agency policy. Evaluate the patient’s tolerance of mechanical ventilation.
■ Verify adequate ventilation and that the patient is breathing in synchrony with the ventilator.
■ Be Safe! Check ABGs and respiratory status about 30 minutes after setup.
■ Monitor continuous pulse oximetry, capnography, and ABGs.
■ Be Smart! When monitoring VS, count spontaneous breaths as well as those delivered by the ventilator.

Key Points
Initial Ventilator Setup
■ Prepare the resuscitation bag; keep it at the bedside.
■ Respiratory therapists are responsible for setting up mechanical ventilation in most agencies. If you must assume the responsibility, refer to the manufacturer’s instructions.
■ Plug in the ventilator and verify settings with the medical prescription.
■ Be Safe! Make sure the ventilator alarm limits are set appropriately.
■ Fill the humidifier with sterile distilled water.
■ Attach the ventilator tubing to the endotracheal tube or tracheostomy tube; secure the ventilator tubing.
■ Attach a capnography device, if available.
■ Prepare the inline suctioning equipment (see Procedure 35-8).

After the Initial Ventilator Setup
■ Wear gloves, protective eye covering, and gown.
■ Check respiratory status and ABGs again about 30 minutes after setup.
■ Be alert for changes in ventilator settings and the patient’s compromised respiratory status.
■ Maintain the patient in a semirecumbent position (head of bed at 30° to 45°).
■ Check the ventilator tubing frequently for condensation.
■ Drain the condensate into a collection device, or briefly disconnect the patient from the ventilator and empty the tubing into a waste receptacle, according to agency policy.
■ Be Safe! Never drain the condensate into the humidifier.
■ Check ventilator and humidifier settings regularly.
■ Check the inline thermometer regularly.
■ Provide alternate form of communication (e.g., letter board, texting using a cell phone or keyboard).
■ Reposition the patient regularly (every 1 to 2 hours), being careful not to pull on the ventilator tubing.
■ Moisten the lips with a cool, damp cloth and water-based lubricant.
■ Provide regular oral care: brush teeth twice a day with a soft toothbrush, moisturize oral mucosa and lips every 2 to 4 hours, use mouthwash twice a day for adult patients.
■ Use a 0.12% CHG rinse twice a day for adult patients who have undergone cardiac surgery.
■ Be Smart! This regimen may help prevent VAP.
■ Ensure that the call light is always within reach, and answer call light and ventilator alarms promptly.
■ Monitor the tracheostomy tube for proper cuff inflation.
■ Monitor for gastric distention.
■ Give sedatives or antianxiety drugs as needed.

Documentation
■ Note:
■ Date and time mechanical ventilation was initiated.
■ Type of ventilator and the prescribed settings used.
■ Patient’s response to mechanical ventilation, including:
• VS.
• Breath sounds.
• Ease of breathing.
• Pulse oximetry.
• I&O.
• Skin color.
• ABG and chest x-ray results.
Preparing the resuscitation bag
Verify ventilator settings
Drain tubing into a waste receptacle, never into the humidifier
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Performing Upper Airway Suctioning

Performing Upper Airway Suctioning

Equipment
■ Portable or wall suction device with connection tubing and a collection canister.
■ Linen-saver pad or towel.
■ Yankauer device (can be used for oropharyngeal suction).
■ Pour-bottle of sterile normal saline solution.
■ Sterile basin or other container for fluids.
■ Face shield or goggles and gown.
■ Procedure gloves.
■ Water-soluble lubricant for nasopharyngeal suctioning.
■ Sputum trap, if a specimen is needed.
■ Biohazard bag.
■ Sterile suction catheter kit (12 to 18 Fr for adults, 8 to 10 Fr for children, and 5 to 8 Fr for infants).
■ If a kit isn’t available, collect the following: sterile suction catheter of the appropriate size, and a sterile container.
■ If you plan to suction both the oropharynx and the nasopharynx, you need a separate sterile catheter for each.

Assessment
■ Assess:
■ Respiratory status, including respiratory rate, depth, and rhythm.
■ Breath sounds.
■ Color.
■ Pulse oximetry results.
■ Note signs that indicate the need for suctioning:
■ Restlessness.
■ Cyanosis.
■ Labored respirations.
■ Decreased oxygen saturation.
■ Increased heart and respiratory rates.
■ Visible secretions in the airway.
■ Presence of adventitious breath sounds during auscultation.
■ Be Safe! You must be certain the patient requires suctioning. Suctioning should be performed only when necessary to prevent unnecessary oxygen desaturation and tissue trauma.

Post-Procedure Reassessment
■ Assess the color, consistency, and amount of secretions.
■ Evaluate the patient’s tolerance of the procedure.
■ Note whether there were signs of respiratory distress during the procedure.
■ Evaluate the effectiveness of the procedure by comparing breath sounds, VS, and pulse oximetry before and after the procedure.

Key Points
■ Position the patient in semi-Fowler’s position.
■ Oropharyngeal: Patient’s face turned toward you.
■ Nasopharyngeal: Neck hyperextended.
■ Adjust the suction regulator according to agency policy (typically 100 to 120 mm Hg for adults, 95 to 110 mm Hg for children, and 50 to 95 mm Hg for infants).
■ If using the nasal approach, open the water-soluble lubricant.
■ Don procedure gloves.
■ Using your dominant hand, attach the suction catheter to the connection tubing.
■ Approximate the depth the suction catheter should be inserted.
■ Remove the oxygen delivery device, if necessary.
■ If the oxygen saturation is less than 94%, or if patient is in distress, administer supplemental oxygen before, during, and after suctioning.
■ Lubricate and insert the suction catheter.
■ Gently advance the catheter the premeasured distance into the pharynx.
■ Engage the suction and apply it while you withdraw the catheter, using a continuous rotating motion.
■ Clear the catheter with sterile saline.
■ Lubricate the catheter, and repeat suctioning as needed, allowing 20-second intervals between suctioning.
■ Be Smart! Upper airway suctioning may be done via the oropharyngeal or nasopharyngeal route. However, nasal suction is usually required to improve oxygenation only in infants because most adult airway obstruction occurs in the mouth and oropharynx.
■ Be Safe! Vigorous nasal suction can induce epistaxis (nosebleed) and further complicate an already difficult airway.

Documentation
■ Record:
■ Date, time, and reason you performed suctioning.
■ Suction technique you used.
■ Catheter size.
■ Note:
■ Color, consistency, and odor of secretions.
■ Patient’s respiratory status before and after the procedure.
■ Patient’s tolerance of the procedure.
■ Any complications that occurred as a result of the procedure.
■ Resulting interventions.

Oropharyngeal suctioning
Nasopharyngeal suctioning
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Performing Tracheostomy or Endotracheal Suctioning (Inline System)

Performing Tracheostomy or Endotracheal Suctioning (Inline System)

Equipment
■ For the once-a-day steps: procedure gloves; inline suction catheter.
■ When suctioning: sterile normal saline.
■ Be Smart! Inline suction is used only with a mechanical ventilator.
■ Linen-saver pad.

Assessment
■ Assess respiratory status (i.e., respiratory rate, depth, and rhythm; breath sounds; color; and pulse oximetry results).
■ Assess for signs that indicate the need for suctioning:
■ Restlessness.
■ Cyanosis.
■ Labored respirations.
■ Decreased oxygen saturation.
■ Increased heart and respiratory rates.
■ Visible secretions in the airway.
■ Presence of adventitious breath sounds during auscultation.

Post-Procedure Reassessment
■ Assess color, amount, and consistency of secretions.
■ Evaluate the patient’s tolerance of the procedure; note signs of
respiratory distress during and after the procedure.
■ Compare breath sounds, VS, and pulse oximetry before and after suctioning.

Key Points
Daily Procedure Steps
■ Prepare the equipment.
■ Open the inline suction catheter package, maintaining sterility.
■ Remove the adapter on the ventilator tubing and attach the suction catheter equipment to the ventilator tubing.
■ Reconnect the adapter on the ventilator tubing.
■ Attach the other end of the inline catheter to the connection tubing going to suction. Suction Procedure Steps
■ Assist the patient to semi-Fowler’s position unless contraindicated.
■ Don clean gloves and place a linen-saver pad on the patient’s chest.
■ Unlock the suction control port.
■ Adjust suction regulator according to guidelines or agency policy.
■ Hyperoxygenate the patient according to agency policy.
■ Unlock the inline catheter; with your dominant hand, insert the suction catheter gently, with suction off. Ask the patient to take slow, deep breaths if she can cooperate.
■ Be Safe! Do not apply suction as you enter or advance into the airway.
■ Be Safe! Advance the suction catheter gently, aiming downward, no further than the carina tracheae (premeasure). Do not force the catheter.
■ Apply continuous suction as you withdraw the catheter, but for no longer than 15 seconds.
■ Avoid saline lavage during suctioning.
■ Be Safe! Repeat suctioning as needed, allowing intervals of at least 30 seconds between suctioning. Make sure to hyperoxygenate the patient between each pass.
■ Withdraw the suction catheter completely into the sleeve, until you see the indicator line.
■ Use normal saline to clear secretions from the catheter. Attach the prefilled, 10-mL container of saline to the saline port on the inline equipment; squeeze the container while applying suction.
■ Lock the suction regulator port.
■ Provide mouth care and reposition the patient.

Documentation
■ Record:
■ Date, time, and reason for suctioning.
■ Size of suction catheter.
■ Amount, color, consistency, and odor of secretions.
■ Respiratory status before and after suctioning.
■ Patient’s tolerance of the procedure.
■ Any complications as a result of the procedure, and interventions performed in response.

Insert into the airway by maneuvering the catheter within the sterilesleeve
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Performing Tracheostomy Care Using Modified Sterile Technique

Performing Tracheostomy Care Using Modified Sterile Technique

Equipment
■ Tracheostomy suction equipment.
■ Tracheostomy care kit or the following sterile supplies:
■ Several cotton-tipped applicators, 2 basins, a brush, sterile 4 in. x 4 in. gauze pads, sterile precut tracheostomy dressing.
■ 2 pairs of procedure gloves.
■ Disposable inner cannula that is the same size as the tracheostomy, if available.
■ Normal saline solution or tap water if agency policy allows.
■ Roll of twill tape or hook-and-loop fastener (Velcro) tracheostomy holder.
■ Bandage scissors.
■ Towel or linen-saver pad.
■ Overbed table.
■ Face shield.
■ Protective gown.
■ Mild soap and 2 clean washcloths.
■ For reusable inner cannula only: hydrogen peroxide.

Assessment
■ Assess respiratory status (i.e., rate, depth, and rhythm; breath sounds; color; and pulse oximetry results).
■ Assess the tracheostomy site for drainage, redness, or swelling.
■ Be Safe! Determine when the patient last ate. Schedule this procedure at least 3 hours after a meal to decrease risk of aspiration.

Post-Procedure Reassessment
■ Assess the area around the stoma site for skin breakdown.
■ Evaluate the patient’s tolerance of the procedure and any signs of respiratory distress.

Key Points
■ Position the patient in semi-Fowler’s position.
■ Don gown, eye protection, and gloves.
■ Suction the tracheostomy.
■ Remove soiled dressing; remove gloves; wash hands.
■ Set up the sterile field and prepare equipment, keeping supplies sterile.
■ Don clean procedure gloves.
■ Remove the oxygen source if the patient is receiving oxygen, offer oxygen blow-by, and attach to the outer cannula. If that is not possible, clean and return the inner cannula before proceeding.
■ Remove the inner cannula with your nondominant hand. If the cannula is disposable, discard it; if the cannula is reusable, clean it.
■ Clean the stoma under the faceplate with the cotton-tipped applicators saturated with normal saline solution or tap water.
■ Clean the top surface of the faceplate and the skin around it with the saline or water-soaked gauze pads, or with a washcloth and tap water. Dry the skin with dry sterile gauze.
■ Be Safe! With the help of an assistant, remove soiled tracheostomy ties/stabilizer. If you must change ties without help, always place the new tape before cutting the soiled tape or holder.
■ Ask the patient to flex his neck, and with an assistant stabilizing the tracheostomy tube, apply new tracheostomy ties.
■ Insert a precut, sterile tracheostomy dressing under the faceplate and new ties.
■ Be Safe! Use only sterile, precut dressing. Or open and refold a 4 in. x 4 in. gauze pad into a V shape. Do not cut 4 in. 4 in. gauze, and do not use cotton-filled gauze squares.

Documentation
■ Document date and time of the tracheostomy care.
■ Note:
■ Color, amount, consistency, and odor of secretions.
■ Condition of the stoma and skin around the stoma site (presence of drainage, redness, or swelling).
■ Record:
■ Respiratory status, including rate, depth, and pattern.
■ Skin color.
■ Breath sounds.
■ Note the patient’s tolerance of the procedure.
■ Document any interventions that were needed.

Disposable tracheostomy equipment
An unfolded and refolded gauze dressing
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Administering Oxygen

Procedure of Administering Oxygen

Equipment
■ Oxygen source.
■ Flow meter.
■ Oxygen tubing.
■ Nasal cannula, oxygen mask, or face tent.
■ Prefilled humidification device.

Assessment
■ Assess patient’s understanding of oxygen therapy.
■ Assess:
■ Respiratory status, including rate, depth, and rhythm.
■ Breath sounds.
■ Color.
■ Capillary refill and pulse oximetry results.
■ Assess nares for patency (if a nasal cannula is being used) and behind the ears for signs of skin breakdown.

Post-Procedure Reassessment
■ Assess respiratory rate, depth, and effort.
■ Auscultate breath sounds before leaving the bedside, then monitor
every 2 to 4 hours, and as indicated.
■ Monitor pulse oximetry until respiratory status improves.
■ Monitor ABG results if prescribed.
■ Evaluate for skin breakdown, especially areas behind the ears, cheekbones, and under the chin—areas that are in contact with the oxygen delivery system.

Key Points
■ Attach the flow meter to the oxygen source. Attach a humidifier to the flow meter, as needed.
■ Assemble and apply the oxygen equipment according to the device prescribed (nasal cannula, face mask, or face tent).
■ Attach the delivery device to the humidifier or the adapter, then put it on the patient:
■ Nasal cannula: Nose prongs should curve downward; loop the tubing around each ear; use the slide device to tighten the cannula under the chin.
■ Face mask: Secure the elastic band around the back of the head.
■ Face tent: Secure like face mask; be sure it fits under the chin.
■ Turn on the oxygen using the flow meter, and adjust according to the prescribed flow rate.
■ Double check that the oxygen equipment is set up correctly and functioning properly.
■ Be Safe! Assess the patient’s respiratory status before you leave the bedside.

Documentation
■ Document:
■ Date, time, and reason oxygen therapy was initiated.
■ Type of oxygen delivery system used.
■ Amount of oxygen administered.
■ Patient’s response to oxygen therapy.
■ Record:
■ VS.
■ Pulse oximetry values.
■ Breath sounds.
■ Skin color.
■ Respiratory effort.

Nasal cannula
Face mask
Face tent
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Monitoring Pulse Oximetry (Arterial Oxygen Saturation)

Monitoring Pulse Oximetry (Arterial Oxygen Saturation)

Equipment
■ Nail polish remover, if necessary.
■ Oximeter.
■ Oximeter probe sensor appropriate for patient age, size, weight, and for the desired location.

Assessment
■ Check patient history for allergy to adhesive.
■ Assess the patient’s need for SaO2 monitoring:
■ Risk factors, such as heart or pulmonary disease.
■ Low hemoglobin level.
■ Confusion, decreased level of consciousness.
■ Respiratory distress.
■ Assess the patient’s:
■ Respiratory status, including breath sounds.
■ Respiratory rate, depth, and pattern.
■ Tissue perfusion.
■ Skin and nailbed color.
■ Determine the optimal location for the oximeter probe sensor (e.g., the fingertip, earlobe, forehead, or bridge of the nose).
■ Check capillary refill and pulse at the pulse closest to the site.
■ Assess for factors that may interfere with pulse oximetry measurement, such as hypotension, hypothermia, and tremors.
■ Be Smart! To ensure accurate monitoring, choose a site that has adequate circulation, is free of artificial nails, and contains no moisture.
■ Be Smart! Use a nasal sensor if peripheral circulation is compromised.

Post-Procedure Reassessment
■ Evaluate the patient’s understanding of the procedure and the obtained values.
■ Compare pulse oximetry results with the patient’s clinical presentation.
■ Evaluate the effectiveness of therapy by comparing SaO2 results before, during, and after treatment.
■ Monitor skin integrity at the site every 4 hours if you are using an adhesive probe sensor or every 2 hours if you are using a clip-on probe sensor.

Key Points
■ Choose a sensor that is appropriate for the patient’s age, size, and weight and for the desired location.
■ Cleanse and dry the site. Remove nail polish, as needed.
■ Attach the probe sensor to the site. Photodetector and light-emitting diodes on the probe sensor should face each other.
■ Connect the sensor probe to the oximeter, and turn it on.
■ Check that the pulse rate on the oximeter corresponds with the patient’s radial pulse.
■ Read the SaO2 measurement on the digital display when it reaches a constant value (usually in 10 to 30 seconds).
■ Set and turn on the alarm limits for SaO2 and pulse rate, according to the manufacturer’s instructions, patient condition, and agency policy if continuous monitoring is necessary.
■ Be Smart! Patients with underlying pulmonary disease may be accustomed to low oxygen saturation levels, so you may need to adjust the lower limit alarm.
■ Be Safe! Rotate the site if monitoring is continuous.
■ When monitoring is no longer needed, remove the probe sensor, and turn off the oximeter.

Documentation
■ Most agencies use a flowsheet if frequent monitoring is necessary.
■ Record the date and time of each pulse oximetry reading obtained; state whether readings are intermittent or continuous.
■ If readings are continuous, record alarm parameters.
■ Chart the patient’s vital signs and SaO2 results, and indicate whether the patient is breathing room air or receiving oxygen therapy.
■ If the patient is receiving oxygen therapy, note the oxygen concentration and the mode of delivery.
■ Document acute decreases in SaO2, any precipitating factors, treatment interventions, and the patient’s response.

Pulse oximetry using a finger probe
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Collecting an Expectorated Sputum Specimen

Collecting an Expectorated Sputum Specimen

Equipment
■ Sterile specimen container with lid.
■ Procedure gloves.
■ Glass of water.
■ Emesis basin.
■ Tissues.
■ Linen-saver pad.
■ Pillow (if abdominal or chest incision is present).
■ Patient identification label.
■ Completed laboratory requisition form.
■ Small plastic bag (or agency-designated container) with a biohazard label for delivering the specimen to the laboratory.

Assessment
■ Assess:
■ Comprehension of the procedure.
■ Ability to deep-breathe, cough, and expectorate.
■ Respiratory status (breath sounds; respiratory rate, depth, and pattern; skin and nailbed color; and tissue perfusion).
■ Be Smart! You may need to delay sputum collection if the patient is in respiratory distress.

Post-Procedure Reassessment
■ Evaluate the patient’s respiratory status during and after the procedure.
■ Examine the color, consistency, and odor of the sputum specimen.
■ Evaluate the patient’s understanding of the procedure and test results.
■ Promptly report laboratory results to the primary care provider.

Key Points
■ Use high- or semi-Fowler’s position.
■ Drape a linen-saver pad over the patient’s chest.
■ Instruct the patient to rinse his mouth and gargle with water.
■ Caution the patient not to touch the inside of the sterile container or lid.
■ Instruct the patient to breathe deeply for 3 or 4 breaths, hold his breath, and then cough and expectorate into the container.
■ Repeat until an adequate sample is obtained (typically 5 to 10 mL).
■ Label the specimen container with patient’s name, test name, and collection date and time.
■ Place the specimen in a plastic bag with a biohazard label. Follow agency policy.
■ Send the specimen to the laboratory immediately.
■ If specimen transport is delayed, consult the lab; refrigeration may be required.

Documentation
■ Record the date and time the specimen was collected, the method of collection, and the type of specimen ordered.
■ Note the amount, color, consistency, and odor of the specimen.
■ Document the patient’s tolerance of the procedure.

Ask the patient to rinse her mouth and gargle
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Emptying a Closed Wound Drainage System

Emptying a Closed Wound Drainage System

Equipment
■ Drainage container with graduated markings.
■ Nonsterile procedure gloves.
■ Disposal sink for biomaterial.
■ Biohazard disposal receptacle.

Assessment
■ Assess the appearance of the drainage tube site and sutures, if in place.
■ Inspect for warmth, edema, redness, or pus where tubing penetrates the skin.
■ Be sure the closed-wound drainage system is securely fastened at the connections and within the wound.
■ Be Smart! Determine whether suction (electric, portable, or manual) is working properly.

Key Points
■ Be Safe! Don PPE as needed, including nonsterile procedure gloves, gown, and eyewear.
■ Properly dispose of contaminated items into designated biohazard waste receptacles.
■ Measure drainage and report excess volume to the primary care provider.

 Documentation
■ Date and time the drainage system is emptied.
■ Volume lost.
■ Excess fluid loss.
■ Appearance of drainage, including presence of blood or purulent material.

Opening the drainage port and emptying the fluid into a graduatedcontainer
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Shortening a Wound Drain

Shortening a Wound Drain

Equipment
■ Nonsterile procedure gloves.
■ Sterile gloves.
■ Sterile scissors.
■ 2 safety pins or other clips (sterile).
■ Sterile gauze.

Assessment
■ Inspect the site around the drain for skin excoriation, tenderness, erythema, warmth to the touch, and drainage from the wound.
■ Assess characteristics of the drainage (color, volume, presence of blood, odor, or pus; and change in type or amount).
■ Check the suction apparatus to be sure it is functioning properly.

Post-Procedure Reassessment
■ Assess the skin around the drain after manipulating it. Note drain patency and be sure the drain is secure.
■ Evaluate for complications occurring related to shortening procedure.

Key Points
■ Using procedure gloves, remove the wound dressing. Discard in a moisture-proof biohazard container.
■ Open sterile supplies and don sterile gloves.
■ Be Smart! If the drain is tightly sutured in place, you might need to cut it with sterile scissors.
■ Be Safe! Firmly grasp the full width of the drain at the level of the skin and pull it out by the prescribed amount (e.g., 6 mm [1/4 in.]).
■ Insert a sterile safety pin through the drain at the level of the skin. Hold the drain tightly, and insert the pin above your fingers.
■ Using sterile scissors, cut the drain a little above the safety pin.

Documentation
■ Record:
■ Amount and characteristics of the drainage.
■ Appearance of the wound.
■ Complications that occur (e.g., manipulation of tubing causes bleeding or drainage at the site).
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12/30/13

Removing Sutures and Staples

Removing Sutures and Staples

Equipment
■ Nonsterile procedure gloves.
■ Suture removal kit or sterile scissors and forceps.
■ Staple remover.
■ Gauze.

Assessment
■ Assess staples to ensure none have rotated or turned instead of lying flat along the incision.

Post-Procedure Reassessment
■ Note whether the incision is well approximated after the procedure.
■ Ensure that the patient verbalized understanding of the treatment.
■ Inspect the wound daily.

Key Points
Suture Removal
■ Place the patient in a comfortable position.
■ Remove the soiled dressing, if necessary.
■ Use the forceps to pick up one end of the suture. Slide the small scissorsnaround the suture, and cut near the skin.
■ With the forceps, gently pull the suture in the direction of the knotted side to remove it. Staple Removal
■ Position the staple remover so that the lower jaw is on the bottom.
■ Place both tips of the lower jaw of the staple remover underneath the staple.
■ Lift slightly on the staple, ensuring that it stays perpendicular to the skin.
■ Gently squeeze the handles together and lift the staple straight up.
■ Place the removed staples on a piece of gauze.
■ Dispose of the removed staples in the sharps container.
■ Apply dressing, if needed.

Documentation
■ Document:
■ Appearance and location of the wound, type and amount of exudates, and odor, if present.
■ Patient’s level of pain before and after the procedure.
■ Method of cleansing the wound and surrounding skin, if performed.
■ Removal of staples or sutures.
■ Education provided to the patient.

Removing interrupted sutures. Clipping the suture near the skin whileusing forceps to hold the knot
Removing a surgical staple
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Applying a Hydrating Dressing (Hydrocolloid or Hydrogel)

Applying a Hydrating Dressing (Hydrocolloid or Hydrogel)

Equipment
■ Clean nonsterile gloves.
■ Hydrating dressing 3 to 4 cm (1.5 in.) larger than the wound.
■ Moisture-proof bag.
■ Obtain the following items only if needed:
■ Sterile normal saline solution for irrigation, warmed to body temperature.
■ Emesis basin.
■ Sterile gauze for cleansing.
■ Disposable clippers or scissors.
■ Skin prep.
■ Measuring device.
■ Tape.

Assessment
■ Assess the area to determine whether a hydrating dressing is appropriate.
■ Determine the size of the wound.

Post-Procedure Reassessment
■ Note whether the dressing adheres comfortably to the skin.
■ Ensure the patient verbalizes understanding of treatment.
■ Inspect the dressing daily.
■ Change it if it becomes dislodged, leaks, or wrinkles or if it develops an odor.
■ Verify that a hydrocolloid dressing is still appropriate for the wound.

Key Points
■ Place the patient in a comfortable position.
■ Remove the soiled dressing, if necessary.
■ Cleanse the wound, if necessary.
■ Assess the wound, or other area where hydrocolloid dressing will be applied, for size, location, appearance, exudate, odor, and signs and symptoms of infection.
■ Be Smart! Clip the hair around the wound if necessary.
■ Apply the hydrating dressing.

Documentation
■ Document:
■ Appearance and location of the wound, type and amount of exudate, and odor, after cleansing.
■ Wound measurements, if taken, and condition of surrounding skin.
■ Method of cleansing the wound and surrounding skin.
■ Type of dressing applied to the wound.
■ Use of skin prep.
■ Education provided to the patient.
■ Assess the patient’s pain level before the procedure.
■ If the patient was medicated for pain, document the drug and dose used, time given, and patient response.

Removing the back of the hydrocolloid dressing
A hydrocolloid dressing after application to the skin
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Applying a Negative Pressure Wound Therapy Device: Open Pore Reticulated Polyurethane Foam (Vacuum Assisted Closure)

Applying a Negative Pressure Wound Therapy Device: Open Pore Reticulated Polyurethane Foam (Vacuum Assisted Closure)

Equipment
■ Suction unit (pump).
■ Collection canister with connecting tubing.
■ Dressing per manufacturer instructions.
■ GranuFoam (black), white or silver foam dressing.
■ TRAC pad.
■ Semipermeable transparent adhesive dressing.
■ Skin preparation product or sealant.
■ Sterile 4 in. 4 in. gauze pad.
■ Clean procedure gloves.
■ 2 pairs of sterile gloves (if using sterile technique).
■ Sterile scissors (if using sterile technique).
■ Waterproof pad.
■ Bath blanket.
■ Goggles or safety glasses, mask, and protective gown.
■ 10- to 20-mL irrigation syringe.
■ Normal saline for irrigation.
■ Emesis basis.
■ Biohazard bag for contaminated materials.

Assessment
■ Assess wound type.
■ Assess for:
■ Contraindication to use of an NPWT (e.g., nonenteric or unexplored fistulas).
■ Necrotic tissue with eschar.
■ Untreated osteomyelitis.
■ Malignancy in the wound or in exposed blood vessels.
■ Anastomotic sites, organs, or nerves.
■ Assess for:
■ Active or prolonged bleeding.
■ Anticoagulant therapy or platelet aggregation inhibitors.
■ Presence of infected, damaged, irradiated, or sutured blood vessels.
■ Assess the wound for:
■ Bone fragments or sharp edges, infection, or pain.
■ Size (length, width, and depth in centimeters).
■ Location and depth of undermining or tunneling.
■ Amount, character, and odor of drainage.
■ Type and percentage of tissue present in wound bed (granulation, slough, fibrin, necrotic).
■ Periwound condition (i.e., intact, denuded, erythema, induration, or maceration).
■ Assess nutritional status.

Post-Procedure Reassessment
■ Note the patient’s response to the procedure.
■ Continue to monitor wound healing and changes in periwound tissues.
■ Monitor dressing every 2 hours to ensure it is firm and collapsed in the wound bed while therapy is on.
■ Monitor the seal of the dressing, and pressure settings.
■ Monitor for brisk or bright bleeding, evisceration or dehiscence, and symptoms of infection.

Key Points
■ Administer an analgesic if needed.
■ Select an appropriate dressing, per NPWT unit, to fill the entire wound cavity.
■ Obtain a suction pump unit as prescribed.
■ Prepare a sterile field for supplies.
■ Don sterile gloves for new surgical wounds, or clean gloves for chronic wounds.
■ Irrigate the wound.
■ Apply appropriate dressing per NPWT unit.
■ Cut the foam to fill the wound cavity.
■ Be Safe! Do not place foam into blind/unexplored tunnels.
■ Be Smart! Do not allow foam dressing to overlap onto healthy skin.
■ Connect tubing attached to the dressing to the evacuation tubing going to the collection system.
■ Be Safe! Position the tubing and connector away from bony prominences and skin creases.
■ Ensure clamps are open on all tubing.
■ Turn on the pump and set to prescribed settings.
■ Listen for audible leaks and observe for dressing collapse or pruning.
■ Change canister once a week or sooner if it fills.

Documentation
■ Record:
■ Date and time of dressing change.
■ Wound assessment: location of the wound, size (length, width, diameter), undermining or tunneling, amount and character of drainage.
■ Odor.
■ Wound bed (including type and percentage of tissue seen, and periwound appearance).
■ Evaluation of therapy with evidence of healing.
■ Treatment selected (type of NPWT, type of gauze or foam, number of pieces placed in the wound).
■ Treatment settings (pressures, intermittent vs. continuous, or variable pressures).
■ Patient response to dressing change.

A foam dressing cut to the size of the wound cavity
Pinching up a piece of the dressing to cut a hole
Applying the suction device for negative pressure wound therapy
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Removing and Applying Wet to Damp Dressings

Removing and Applying Wet to Damp Dressings

Equipment
■ 3 pairs of clean nonsterile gloves.
■ Sterile solution or tap water for irrigation, warmed to body temperature when possible.
■ Water-resistant disposable drapes.
■ Sterile fine-mesh gauze in a tray for dressing.
■ Surgipad.
■ Tape or Montgomery straps.

Assessment
■ Assess:
■ Amount and type of tissue present in the wound bed.
■ Type and amount of exudate.
■ Wound odor.
■ Tissue surrounding the wound edge.
■ Patient pain.

Post-Procedure Reassessment
■ Verify that the patient experiences minimal discomfort with the procedure.
■ Note whether the patient verbalizes understanding of the procedure.

Key Points
■ Assess for pain, and medicate 30 minutes before procedure, if necessary.
■ Place the patient in a comfortable position that provides easy access to the wound.
■ Wearing clean gloves, remove the soiled dressing and discard it in a biohazard receptacle.
■ Be Safe! Change gloves and cleanse the wound with gauze moistened with sterile saline or tap water.
■ Assess the wound for location, appearance, odor, and drainage.
■ Don clean gloves and apply a single layer of moist, fine-mesh gauze to the wound. Be sure to place gauze in all depressions of the wound.
■ Apply a secondary moist layer over the first layer. Repeat this process until the wound is filled with moistened sterile gauze.
■ Cover the moistened gauze with a surgipad.
■ Be Smart! Secure the dressing with tape or Montgomery straps.

Documentation
■ Record:
■ Appearance and location of the wound, type and amount of exudate, and odor after cleansing.
■ Patient’s pain level before the procedure.
■ Pain medication given including the dose, time, your name, and the patient’s response.
■ Method of cleansing the wound.
■ Type of dressing applied to the wound.
■ Education provided to the patient.

Removing a wet-to-damp dressing
Packing a wet to damp dressing
Covering a wet to damp dressing
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Performing Sterile Wound Irrigation

Performing Sterile Wound Irrigation

Equipment
■ Clean gloves.
■ Sterile gloves.
■ Gown and face shield.
■ Water-resistant, disposable drapes.
■ Tepid (body temperature) irrigation solution.
■ Sterile gauze.
■ Dressing supplies.
■ Biohazard waste container.
■ Sterile impermeable barrier.
■ Sterile bowl.
■ Sterile piston syringe or commercial irrigation kit (if irrigating with a syringe).
■ If using an angiocatheter:
• Sterile emesis basin.
• 35-mL syringe.
• 19-gauge angiocatheter (with needle removed).

Assessment
■ If the wound is covered when you begin, you will make these assessments when you remove the soiled dressing and after cleansing the wound:
■ Amount and type of tissue present in the wound bed.
■ Whether the wound requires sterile, modified sterile, or clean technique for irrigation.
■ Assess the wound for:
• Signs of infection (erythema, induration, amount and type of drainage).
• Odor.
• Periwound tissue.
• Patient pain.

Post-Procedure Reassessment
■ Determine whether the patient remains comfortable. If not, medicate according to prescriptions.
■ Reassess the wound at regular intervals.

Key Points
■ Administer pain medication 30 minutes before the procedure, if necessary.
■ Position the patient for easy access to the wound and in a manner that will allow the irrigation solution to flow freely from the wound with the assistance of gravity.
■ Be Safe! Don protective equipment: gown, face shield, and clean gloves.
■ Remove the soiled dressing, and dispose of gloves.
■ Set up a sterile field with a sterile irrigation kit or a 35-mL syringe and a 19-gauge angiocatheter (needle removed), dressing supplies, and irrigation solution.
■ Wearing sterile gloves, fill either the syringe and angiocatheter or the piston-tip syringe with irrigation solution.
■ Be Smart! Holding the syringe tip 2 cm (3/4 to 1 in.) from the wound bed, gently irrigate the wound with a back-and-forth motion, moving from the superior aspect to the inferior aspect.
■ Dry the tissue surrounding the wound with sterile gauze.
■ Apply a new dressing as prescribed.
■ Dispose of used equipment and soiled dressings in a biohazard waste container.
■ Reposition the patient.

Documentation
■ Document:
■ Appearance and location of the wound, size, tissue in wound base, periwound tissue, type and amount of exudate, and odor, after irrigation.
■ Patient’s pain level.
■ If the patient was medicated for pain, document the drug and dose used, time given, and patient response.
■ Record:
■ Method by which the wound was cleansed.
■ Dressing reapplied to the wound, if applicable.
■ Education provided to the patient.

Performing a sterile wound irrigation using a syringe
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Obtaining a Wound Culture by Swab

Obtaining a Wound Culture by Swab

Equipment
■ 3 pairs of clean procedure gloves.
■ Culturette tube.
■ Sterile 4 in. x 4 in. gauze pad in an impermeable tray or separate 4 x 4 packs and an impermeable barrier.
■ Sterile 0.9% (normal) saline solution for irrigation, warmed to body temperature.
■ 35-mL syringe.
■ 19-gauge angiocatheter.
■ Gown and face shield.
■ Emesis basin.
■ Water-resistant disposable drapes.

Assessment
■ If the wound is covered when you begin, you will make these assessments when you remove the soiled dressing and after cleansing the wound:
■ Assess for pain.
■ Determine whether the wound requires sterile, modified sterile, or clean technique.
■ Assess:
• Amount and type of tissue present in the wound bed.
• Type and amount of exudate.
• Wound for odor.
• Tissue surrounding the wound edge.

Post-Procedure Reassessment
■ Assess patient’s pain level and medicate according to prescriptions.
■ Monitor lab reports for results of the swab culture.

Key Points
■ Be Smart! Position the patient for easy access to the wound and in a manner that will allow the irrigation solution to flow freely from the wound with the assistance of gravity.
■ Be Safe! Don protective equipment: gown, face shield, and clean procedure gloves.
■ Remove the soiled dressing and dispose of gloves and dressing.
■ Don clean gloves, and fill a 35-mL syringe with attached 19-gauge angiocatheter with 0.9% (normal) saline solution.
■ Holding the angiocatheter tip 2 cm (3/4 to 1 in.) from the wound bed, gently irrigate the wound (superior to inferior).
■ Press the culture swab against an area of red granulating tissue, and rotate.
■ Reinsert the swab into the culturette tube, label the tube, and transport it to the lab.

Documentation
■ Chart:
■ Appearance and location of the wound and surrounding tissue, noting the type, consistency, and amount of exudate, and odor.
■ Patient’s pain level before the culture. (If the patient was medicated for pain, document the drug and dose used, time given, and patient response.)
■ Method by which the wound was cleansed before the culture.
■ Description of the area where the culture was obtained.
■ Dressing reapplied to wound, if applicable.
■ Education provided to the patient.

Collecting a wound culture by swab
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Procedure of Assisting With Ambulation

Procedure of Assisting With Ambulation

Equipment
■ Nonlatex gloves, if you may be exposed to body fluids.
■ Transfer belt.

Assessment
■ Assess:
■ Level of consciousness, ability to follow directions, and ability to assist with ambulation.
■ Physical size of the patient and your own ability to move the patient.
■ Factors that may increase the risk of falls (elderly, muscle strength, chronic disease, gait disturbance).
■ Any restrictions in movement or position.
■ Patient’s level of comfort.
■ Presence of equipment such as IV lines, drains, or catheters.
■ Possible side effects of medications (e.g., dizziness and sedation).
■ VS (monitor for postural hypotension).

Post-Procedure Reassessment
■ Assess:
■ Level of patient participation in the transfer.
■ Patient’s comfort with ambulation.
■ Posture and base of support.
■ VS for postural hypotension.

Key Points
■ Have the patient wear nonskid footwear.
■ Be Safe! Place the bed in low position, and lock the wheels.
■ Assist the patient to dangle at the side of the bed; assess the patient’s tolerance before beginning ambulation.
■ If two nurses are available to assist with the transfer, one nurse should be on each side of the patient.
■ Be Safe! Brace your feet and knees against the patient. Bend your hips and knees, and hold onto the transfer belt. Pay attention to any known weakness.
■ Instruct the patient to place her arms around you between your shoulders and waist (the location depends on the height of the patient and the nurses). Ask the patient to stand as you move to an upright position by straightening your legs and hips.
■ Allow the patient to steady herself for a moment.
■ One nurse: Stand at the patient’s side, placing both hands on the transfer belt. If the patient has weakness on one side, position yourself on the weaker side.
■ Two nurses: One nurse is on each side of the patient, grasping the transfer belt.
■ Slowly guide the patient forward. Observe for signs of fatigue or dizziness.
■ Be Safe! If the patient has an IV pole, allow the patient to hold onto the pole on the side where you are standing but not to use it for full support. Assist the patient to advance the pole as you ambulate together.

Documentation
■ Record:
■ The amount of assistance required.
■ Any problems with ambulation.
■ The distance walked.

Stand at the patient's side, placing both hands on the transfer belt
Assist the patient to advance the IV pole as he ambulates
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Transferring a Patient From Bed to Chair

Transferring a Patient From Bed to Chair

Equipment
■ Nonlatex gloves, if you may be exposed to body fluids.
■ Transfer roller sheet.
■ Transfer board.
■ Gait transfer belt.

Assessment
■ Assess:
■ Level of consciousness, ability to follow directions, and ability to assist with the move.
■ Patient’s physical size and your own ability to move her.
■ Restrictions in movement or position.
■ Patient’s level of comfort.
■ Presence of equipment such as IV lines, drains, or catheters.
■ Possible side effects of medications (e.g., dizziness and sedation).
■ VS.
■ Monitor for postural hypotension.
■ Before transferring a patient to a chair, assess her tolerance of dangling.

Post-Procedure Reassessment
■ Level of patient participation in the transfer.
■ Comfort level during the transfer and in the new position.
■ Proper body position and alignment after position change.
■ VS for postural hypotension.

Key Points
■ Be Safe! Instruct the patient to wear nonskid footwear (slippers or shoes).
■ Place the bed in the low position, and lock the wheels.
■ Assist the patient to dangle at the side of the bed.
■ Brace your feet and knees against the patient. Bend your hips and knees, and hold onto the transfer belt.
■ If two nurses are available to assist with the transfer, one nurse should be on each side of the patient.
■ Be Smart! Instruct the patient to place her arms around you between your shoulders and waist. (The location depends on the height of the patient and the nurses.) Ask the patient to stand as you move to an upright position by straightening your legs and hips.
■ Instruct the patient to pivot and turn with you toward the chair.
■ Ask the patient to flex her hips and knees as she lowers herself to the chair. Guide her motion while maintaining a firm hold on her.
■ Be Safe! If the chair is a wheelchair, lock the wheels.

Documentation
■ Moving patients to a chair is a routine aspect of care and may not be documented.
■ For nursing notes, document:
■ How much assistance was required.
■ Use of assistive devices.
■ Any problems with positioning the patient.
■ How long the patient was out of bed.
■ How the patient tolerated the activity.

Transferring a patient from bed to chair by bracing feet and kneesagainst the patient
Transferring a patient from bed to chair using a transfer belt
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Dangling a Patient at the Side of the Bed

Dangling a Patient at the Side of the Bed

Equipment
■ Nonlatex gloves, if you may be exposed to body fluids.
■ Transfer roller sheet or transfer board, if needed.
■ Gait transfer belt.

Assessment
■ Assess:
■ Level of consciousness, ability to follow directions, and ability to assist with the move.
■ The patient’s physical size and your own ability to move him.
■ Restrictions in movement or position.
■ Patient’s level of comfort; presence of equipment such as IV lines, drains, or catheters; possible side effects of medications (e.g., dizziness and sedation).
■ VS.
■ Monitor for postural hypotension.
■ Before transferring a patient to a chair, assess his tolerance of dangling.

Post-Procedure Reassessment
■ Assess:
■ Level of patient participation in the transfer.
■ Comfort level during the transfer and in the new position.
■ Proper body position and alignment after position change.
■ VS for postural hypotension.

Key Points
■ Place the patient supine, and raise the head of the bed to 90°.
■ Be Safe! Apply a gait transfer belt, and put the bed in the low position with wheels locked.
■ Stand facing the patient with a wide base of support. Place your foot closest to the head of the bed forward of the other foot.
■ Position your hands on each side of the gait transfer belt.
■ Rock onto your back foot as you move the patient into a sitting position; pivot to bring the patient’s legs over the side of the bed.
■ Be Smart! Stay with the patient as he dangles.

Documentation
■ For nursing notes, document:
■ How much assistance was required.
■ Use of assistive devices.
■ Any problems with positioning the patient.
■ How long the patient was dangling.
■ How the patient tolerated the activity.

Using proper body mechanics for dangling a patient at the side of the bed
Pivoting the patient’s legs to a dangle position
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Procedure of Logrolling a Patient

Procedure of Logrolling a Patient

Equipment
■ Nonlatex gloves, if you may be exposed to body fluids.
■ Friction-reducing device, such as a transfer roller sheet or scoot sheet.
■ Pull or lift (draw) sheet; pillows, as needed.

Assessment
■ Assess:
■ Level of consciousness, ability to follow directions, and ability to assist with the move.
■ Any restrictions in movement or position.
■ Level of comfort.
■ Physical size of the patient.
■ Assistive devices available.
■ Presence of equipment such as IV setups, pumps, or casts.

Post-Procedure Reassessment
■ Assess the patient’s comfort level, body position and alignment, and skin for pressure areas.

Key Points
■ Move the patient as a unit to the opposite side of the bed; raise the siderail on that side.
■ Be Smart! Move to the side of the bed that the patient will be turning toward; lower the siderail.
■ Be Safe! Each staff member evenly distributes his arms across the patient’s length. One nurse is responsible for moving the head and neck as a unit.
■ Shift your weight backward as you roll the patient toward you.

Documentation
■ Repositioning is not usually charted every time it is done; often it is recorded on a flowsheet.
■ Document in the nursing notes any problems with the procedure or any areas of skin breakdown.
■ You might also document turning as an intervention when charting toa specific problem. For example, for Impaired Skin Integrity, you might chart, “Position changed hourly.”

Logrolling a patient using a transfer roller sheet
Logrolling a patient using proper body mechanics
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Moving a Patient Up in Bed

Moving a Patient Up in Bed

Equipment
■ Nonlatex gloves, if you may be exposed to body fluids.
■ Friction-reducing device, such as a transfer roller sheet or scoot sheet.
■ Pull or lift (draw) sheet; pillows, as needed.

Assessment
■ Assess:
■ Level of consciousness, ability to follow directions, and ability to assist with the move.
■ Any restrictions in movement or position.
■ Level of comfort, physical size, and assistive devices available.
■ Equipment in use, such as IV setups, pumps, or casts.

Post-Procedure Reassessment
■ Assess:
■ Patient’s comfort level.
■ Body position and alignment.
■ Skin for pressure areas.

Key Points
■ Be Safe! Use a friction-reducing device to move the patient if the patient can assist with movement. Use a full body sling if the patient cannot assist.
■ Remove the pillow. Have the patient flex her neck, fold her arms across her chest, and place her feet flat on bed.
■ Position a nurse on either side of the patient.
■ Be Smart! Use a wide base of support.
■ Have the patient, on the count of 3, push off with her heels as you shift your weight forward.

Documentation
■ Repositioning is not usually charted every time it is done; often it is recorded on a flowsheet.
■ Document any problems with repositioning the patient or any areas of skin breakdown.
■ You might also document turning as an intervention when charting to a specific problem. For example, for Impaired Skin Integrity, you might chart, “Position changed hourly.

Move a patient up in bed using a trapeze
Move a patient up in bed using a mechanical device
Use a drawsheet to turn the patient to one side of the bed
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