12/20/13

Suctioning an Endotracheal Tube: Open System

Goal: The patient exhibits improved breath sounds and a clear, patent airway.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible.

5. Determine the need for suctioning. Verify the suction order in the patient’s chart. Assess for pain or the potential to cause pain. Administer pain medication, as prescribed, before suctioning.

6. Explain what you are going to do and the reason for doing it to the patient, even if the patient does not appear to be alert. Reassure the patient you will interrupt the procedure if he or she indicates respiratory difficulty.

7. Adjust bed to comfortable working position, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Lower side rail closest to you. If patient is conscious, place him or her in a semi-Fowler’s position. If patient is unconscious, place him or her in the lateral position, facing you. Move the overbed table close to your work area and raise it to waist height.

8. Place towel or waterproof pad across patient’s chest.

9. Turn suction to appropriate pressure. For a wall unit for an adult: 100–120 mm Hg (Roman, 2005); neonates: 60–80 mm Hg; infants: 80–100 mm Hg; children: 80–100 mm Hg; adolescents: 80–120 mm Hg (Ireton, 2007). For a portable unit for an adult: 10–15 cm Hg; neonates: 6–8 cm Hg; infants 8–10 cm Hg; children 8–10 cm Hg; adolescents: 8–10 cm Hg.

10. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure. Place the connecting tubing in a convenient location. Place the resuscitation bag connected to oxygen within convenient reach, if using.

11. Open sterile suction package using aseptic technique. The open wrapper becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it.

12. Put on face shield or goggles and mask. Put on sterile gloves. The dominant hand will manipulate the catheter and must remain sterile. The nondominant hand is
considered clean rather than sterile and will control the suction valve (Y-port) on the catheter.

13. With dominant gloved hand, pick up sterile catheter. Pick up the connecting tubing with the nondominant hand and connect the tubing and suction catheter.

14. Moisten the catheter by dipping it into the container of sterile saline, unless it is a silicone catheter. Occlude Y-tube to check suction.

15. Hyperventilate the patient using your nondominant hand and a manual resuscitation bag and delivering three to six breaths or use the sigh mechanism on a mechanical
ventilator.

16. Open the adapter on the mechanical ventilator tubing or remove the manual resuscitation bag with your nondominant hand.

17. Using your dominant hand, gently and quickly insert the catheter into the trachea. Advance the catheter to the predetermined length. Do not occlude Y-port when inserting the catheter.

18. Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand, and gently rotate the catheter as it is being withdrawn. Do not suction for more than 10 to 15 seconds at a time.

19. Hyperventilate the patient using your nondominant hand and a manual resuscitation bag and delivering three to six breaths. Replace the oxygen delivery device, if applicable, using your nondominant hand and have the patient take several deep breaths. If the patient is mechanically ventilated, close the adapter on the mechanical ventilator tubing or replace the ventilator tubing and use the sigh mechanism on a mechanical ventilator.

20. Flush catheter with saline. Assess the effectiveness of suctioning and repeat, as needed, and according to patient’s tolerance. Wrap the suction catheter around your dominant hand between attempts.

21. Allow at least a 30-second to 1-minute interval if additional suctioning is needed. No more than three suction passes should be made per suctioning episode. Suction the oropharynx after suctioning the trachea. Do not reinsert in the endotracheal tube after suctioning the mouth.

22. When suctioning is completed, remove gloves from dominant hand over the coiled catheter, pulling it off inside-out. Remove glove from nondominant hand and dispose of gloves, catheter, and container with solution in the appropriate receptacle. Assist patient to a comfortable position. Raise bed rail and place bed in the lowest position.

23. Turn off suction. Remove face shield or goggles and mask. Perform hand hygiene.

24. Offer oral hygiene after suctioning.

25. Reassess patient’s respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds.

26. Remove additional PPE, if used. Perform hand hygiene.
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Inserting an Oropharyngeal Airway

Goal: The patient sustains a patent airway.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible.

5. Explain to the patient what you are going to do and the reason for doing it, even though the patient does not appear to be alert.

6. Put on disposable gloves; put on goggles or face shield, as indicated.

7. Measure the oropharyngeal airway for correct size. Measure the oropharyngeal airway by holding the airway on the side of the patient’s face. The airway should reach
from the opening of the mouth to the back angle of the jaw.

8. Check mouth for any loose teeth, dentures, or other foreign material. Remove dentures or material if present.

9. Position patient in semi-Fowler’s position.

10. Suction patient, if necessary.

11. Open patient’s mouth by using your thumb and index finger to gently pry teeth apart. Insert the airway with the curved tip pointing up toward the roof of the mouth.

12. Slide the airway across the tongue to the back of the mouth. Rotate the airway 180 degrees as it passes the uvula. The tip should point down and the curvature should follow the contour of the roof of the mouth. A flashlight can be used to confirm the position of the airway with the curve fitting over the tongue.

13. Ensure accurate placement and adequate ventilation by auscultating breath sounds.

14. Position patient on his or her side when airway is in place.

15. Remove gloves and additional PPE, if used. Perform hand hygiene.

16. Remove the airway for a brief period every 4 hours, or according to facility policy. Assess mouth, provide mouth care, and clean the airway according to facility policy before reinserting it.
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Suctioning the Nasopharyngeal and Oropharyngeal Airways

Goal: The patient exhibits improved breath sounds and a clear, patent airway.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible.

5. Determine the need for suctioning. Verify the suction order in the patient’s chart, if necessary. For a postoperative patient, administer pain medication before suctioning.

6. Explain what you are going to do and the reason for suctioning to the patient, even if the patient does not appear to be alert. Reassure the patient you will interrupt procedure if he or she indicates respiratory difficulty.

7. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Lower side rail closest to you. If patient is conscious, place him or her in a semi-Fowler’s position. If patient is unconscious, place him or her in the lateral position, facing you. Move the bedside table close to your work area and raise it to waist height.

8. Place towel or waterproof pad across the patient’s chest.

9. Adjust suction to appropriate pressure. For a wall unit for an adult: 100–120 mm Hg (Roman, 2005); neonates: 60–80 mm Hg; infants: 80–100 mm Hg; children: 80–100 mm Hg; adolescents: 80–120 mm Hg (Ireton, 2007). For a portable unit for an adult: 10–15 cm Hg; neonates: 6–8 cm Hg; infants: 8–10 cm Hg; children: 8–10 cm Hg;
adolescents: 8–10 cm Hg. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure. Place the connecting tubing in a convenient location.

10. Open sterile suction package using aseptic technique. The open wrapper or container becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it.

11. Place a small amount of water-soluble lubricant on the sterile field, taking care to avoid touching the sterile field with the lubricant package.

12. Increase the patient’s supplemental oxygen level or apply supplemental oxygen per facility policy or primary care provider order.

13. Put on face shield or goggles and mask. Put on sterile gloves. The dominant hand will manipulate the catheter and must remain sterile. The nondominant hand is
considered clean rather than sterile and will control the suction valve (Y-port) on the catheter.

14. With dominant gloved hand, pick up sterile catheter. Pick up the connecting tubing with the nondominant hand and connect the tubing and suction catheter.

15. Moisten the catheter by dipping it into the container of sterile saline. Occlude Y-tube to check suction.

16. Encourage the patient to take several deep breaths.

17. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was placed on the sterile field.

18. Remove the oxygen delivery device, if appropriate. Do not apply suction as the catheter is inserted. Hold the catheter between your thumb and forefinger.

19. Insert the catheter:
a. For nasopharyngeal suctioning, gently insert catheter through the naris and along the floor of the nostril toward the trachea. Roll the catheter between your fingers to help advance it. Advance the catheter approximately 5 to 6 to reach the pharynx.
b. For oropharyngeal suctioning, insert catheter through the mouth, along the side of the mouth toward the trachea. Advance the catheter 3 to 4 to reach the pharynx. (See the Skill Variation in your skills book for nasotracheal suctioning.)

20. Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand and gently rotating the catheter as it is being withdrawn. Do not suction for more than 10 to 15 seconds at a time.

21. Replace the oxygen delivery device using your nondominant hand, if appropriate, and have the patient take several deep breaths.

22. Flush catheter with saline. Assess effectiveness of suctioning and repeat, as needed, and according to patient’s tolerance. Wrap the suction catheter around your dominant hand between attempts.

23. Allow at least a 30-second to 1-minute interval if additional suctioning is needed. No more than three suction passes should be made per suctioning episode.
Alternate the nares, unless contraindicated, if repeated suctioning is required. Do not force the catheter through the nares. Encourage the patient to cough and deep
breathe between suctioning. Suction the oropharynx after suctioning the nasopharynx.

24. When suctioning is completed, remove gloves from dominant hand over the coiled catheter, pulling them off inside out. Remove glove from nondominant hand and dispose of gloves, catheter, and container with solution in the appropriate receptacle. Assist patient to a comfortable position. Raise bed rail and place bed in the lowest position.

25. Turn off suction. Remove supplemental oxygen placed for suctioning, if appropriate. Remove face shield or goggles and mask. Perform hand hygiene.

26. Offer oral hygiene after suctioning.

27. Reassess patient’s respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds.

28. Remove additional PPE, if used. Perform hand hygiene.
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Using an Oxygen Tent

Goal: The patient exhibits an oxygen saturation level within acceptable parameters.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible.

5. Explain what you are going to do and the reason for doing it to the patient and parents/guardians. Review safety precautions necessary when oxygen is in use.

6. Calibrate the oxygen analyzer according to manufacturer’s directions.

7. Place tent over crib or bed. Connect the humidifier to the oxygen source in the wall and connect the tent tubing to the humidifier. Adjust flow rate as ordered by physician. Check that oxygen is flowing into tent.

8. Turn analyzer on. Place oxygen analyzer probe in tent, out of patient’s reach.

9. Adjust oxygen as necessary, based on sensor readings. Once oxygen levels reach the prescribed amount, place patient in the tent.

10. Roll small blankets like a jelly roll and tuck tent edges under blanket rolls, as necessary.

11. Encourage patient and family members to keep tent flap closed.

12. Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, grunting, retractions, or dyspnea.

13. Remove PPE, if used. Perform hand hygiene.

14. Frequently check bedding and patient’s pajamas for moisture. Change as needed to keep the patient dry.
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Administering Oxygen by Mask

Goal: The patient exhibits an oxygen saturation level within acceptable parameters.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible.

5. Explain what you are going to do and the reason for doing it to the patient. Review safety precautions necessary when oxygen is in use. Place “No Smoking” signs in appropriate areas.

6. Attach face mask to oxygen source (with humidification, if appropriate, for the specific mask). Start the flow of oxygen at the specified rate. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the next step.

7. Position face mask over the patient’s nose and mouth. Adjust the elastic strap so that the mask fits snugly but comfortably on the face. Adjust the flow rate to the
prescribed rate.

8. If the patient reports irritation or redness is noted, use gauze pads under the elastic strap at pressure points to reduce irritation to ears and scalp.

9. Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea.

10. Remove PPE, if used. Perform hand hygiene.

11. Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. Do not use powder around the mask.
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Administering Oxygen by Nasal Cannula

Goal: The patient exhibits an oxygen saturation level within acceptable parameters.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible.

5. Explain what you are going to do and the reason for doing it to the patient. Review safety precautions necessary when oxygen is in use. Place “No Smoking” signs in appropriate areas.

6. Connect nasal cannula to oxygen setup with humidification, if one is in use. Adjust flow rate as ordered. Check that oxygen is flowing out of prongs.

7. Place prongs in patient’s nostrils. Place tubing over and behind each ear with adjuster comfortably under chin. Alternately, the tubing may be placed around the patient’s head, with the adjuster at the back or base of the head. Place gauze pads at ear beneath the tubing, as necessary.

8. Adjust the fit of the cannula, as necessary. Tubing should be snug but not tight against the skin.

9. Encourage patient to breathe through the nose, with the mouth closed.

10. Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea.

11. Remove PPE, if used. Perform hand hygiene.

12. Put on clean gloves. Remove and clean the cannula and assess nares at least every 8 hours, or according to agency recommendations. Check nares for evidence of irritation or bleeding.
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Teaching Patient to Use an Incentive Spirometer

Goal: The patient accurately demonstrates the procedure for using the spirometer.

1. Review chart for any health problems that would affect the patient’s oxygenation status.

2. Bring necessary equipment to the bedside stand or overbed table.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient.

6. Assist patient to an upright or semi-Fowler’s position, if possible. Remove dentures if they fit poorly. Assess the patient’s level of pain. Administer pain medication, as prescribed, if needed. Wait the appropriate amount of time for the medication to take effect. If patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting.

7. Demonstrate how to steady the device with one hand and hold the mouthpiece with the other hand. If the patient cannot use hands, assist the patient with the incentive spirometer.

8. Instruct the patient to exhale normally and then place lips securely around the mouthpiece.

9. Instruct patient to inhale slowly and as deeply as possiblethrough the mouthpiece without using nose (if desired, a nose clip may be used).

10. When the patient cannot inhale anymore, the patient should hold his or her breath and count to three. Check position of gauge to determine progress and level attained. If patient begins to cough, splint an abdominal or chest incision.

11. Instruct the patient to remove lips from mouthpiece and exhale normally. If patient becomes light-headed during the process, tell him or her to stop and take a few normal breaths before resuming incentive spirometry.

12. Encourage patient to perform incentive spirometry 5 to 10 times every 1 to 2 hours, if possible.

13. Clean the mouthpiece with water and shake to dry. Remove PPE, if used. Perform hand hygiene.
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Using a Pulse Oximeter

Goal: The patient exhibits arterial blood oxygen saturation within acceptable parameters, or greater than 95%.

1. Review chart for any health problems that would affect the patient’s oxygenation status.

2. Bring necessary equipment to the bedside stand or overbed table.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient.

6. Select an adequate site for application of the sensor.
a. Use the patient’s index, middle, or ring finger.
b. Check the proximal pulse and capillary refill at the pulse closest to the site.
c. If circulation at the site is inadequate, consider using the earlobe, forehead, or bridge of nose.
d. Use a toe only if lower extremity circulation is not compromised.

7. Select proper equipment:
a. If one finger is too large for the probe, use a smaller one. A pediatric probe may be used for a small adult.
b. Use probes appropriate for patient’s age and size.
c. Check if patient is allergic to adhesive. A nonadhesive finger clip or reflectance sensor is available.
8. Prepare the monitoring site. Cleanse the selected area with the alcohol wipe or disposable cleansing cloth. Allow the area to dry. If necessary, remove nail polish
and artificial nails after checking pulse oximeter’s manufacturer instructions.

9. Apply probe securely to skin. Make sure that the lightemitting sensor and the light-receiving sensor are aligned opposite each other (not necessary to check if placed on forehead or bridge of nose).

10. Connect the sensor probe to the pulse oximeter, turn the oximeter on, and check operation of the equipment (audible beep, fluctuation of bar of light or waveform on face of oximeter).

11. Set alarms on pulse oximeter. Check manufacturer’s alarm limits for high and low pulse rate settings.

12. Check oxygen saturation at regular intervals, as ordered by primary care provider, nursing assessment, and signaled by alarms. Monitor hemoglobin level.

13. Remove sensor on a regular basis and check for skin irritation or signs of pressure (every 2 hours for spring-tension sensor or every 4 hours for adhesive finger or toe sensor).

14. Clean nondisposable sensors according to the manufacturer’s directions. Remove PPE, if used. Perform hand hygiene.
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Irrigating a Nasogastric Tube Connected to Suction

Goal: The tube maintains patency with irrigation and patient remains free from injury.

1. Assemble equipment. Verify the medical order or facility policy and procedure regarding frequency of irrigation, solution type, and amount of irrigant. Check expiration dates on irrigating solution and irrigation set.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed. Perform key abdominal assessments as described above.

5. Pull the patient’s bedside curtain. Raise bed to a comfortable working position, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Assist patient to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into container.

6. Put on gloves. Check placement of NG tube. (Refer to Skill 11-2.)

7. Draw up 30 mL of saline solution (or amount indicated in the order or policy) into syringe.

8. Clamp suction tubing near connection site. If needed, disconnect tube from suction apparatus and lay on disposable pad or towel, or hold both tubes upright in nondominant hand.

9. Place tip of syringe in tube. If Salem sump or doublelumen tube is used, make sure that syringe tip is placed in drainage port and not in blue air vent. Hold syringe upright and gently insert the irrigant (or allow solution to flow in by gravity if agency policy or physician indicates). Do not force solution into tube.

10. If unable to irrigate tube, reposition patient and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again. Check with physician or follow agency policy, if repeated attempts to irrigate tube fail.

11. After irrigant has been instilled, hold end of NG tube over irrigation tray or emesis basin. Observe for return flow of NG drainage into available container. Alternately, you may reconnect the NG tube to suction and observe the return drainage as it drains into the suction container.

12. If not already done, reconnect drainage port to suction, if ordered.

13. Inject air into blue air vent after irrigation is complete. Position the blue air vent above the patient’s stomach.

14. Remove gloves. Lower the bed and raise side rails, as necessary. Assist the patient to a position of comfort. Perform hand hygiene.

15. Put on gloves. Measure returned solution, if collected outside of suction apparatus. Rinse equipment if it will be reused. Label with the date, patient’s name, room number, and purpose (for NG tube/irrigation).

16. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Irrigating a Colostomy

Goal: The patient expels soft, formed stool.

1. Verify the order for the irrigation. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Plan where the patient will receive irrigation. Assist patient onto bedside commode or into nearby bathroom.

5. Warm solution in amount ordered and check temperature with a bath thermometer, if available. If bath thermometer is not available, warm to room temperature or slightly higher, and test on inner wrist. If tap water is used, adjust temperature as it flows from faucet.

6. Add irrigation solution to container. Release clamp and allow fluid to progress through tube before reclamping.

7. Hang container so that bottom of bag will be at patient’s shoulder level when seated.

8. Put on nonsterile gloves.

9. Remove ostomy appliance and attach irrigation sleeve. Place drainage end into toilet bowl or commode.

10. Lubricate end of cone with water-soluble lubricant.

11. Insert the cone into the stoma. Introduce solution slowly over a period of 5 to 6 minutes. Hold cone and tubing (or if patient is able, allow patient to hold) all the time that solution is being instilled. Control rate of flow by closing or opening the clamp.

12. Hold cone in place for an additional 10 seconds after the fluid is infused.

13. Remove cone. Patient should remain seated on toilet or bedside commode.

14. After majority of solution has returned, allow patient to clip (close) bottom of irrigating sleeve and continue with daily activities.

15. After solution has stopped flowing from stoma, put on clean gloves. Remove irrigating sleeve and cleanse skin around stoma opening with mild soap and water. Gently
pat peristomal skin dry.

16. Attach new appliance to stoma or stoma cover (see Skill 13-6), as needed.

17. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry, if appropriate. Ensure that the patient is covered.

18. Raise side rail. Lower bed height and adjust head of bed to a comfortable position, as necessary.

19. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Changing and Emptying an Ostomy Appliance

Goal: The stoma appliance is applied correctly to the skin to allow stool to drain freely.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Encourage the patient to observe or participate, if possible.

5. Assist patient to a comfortable sitting or lying position in bed or a standing or sitting position in the bathroom.

Emptying an Appliance
6. Put on disposable gloves. Remove clamp and fold end of pouch upward like a cuff.

7. Empty contents into bedpan, toilet, or measuring device.

8. Wipe the lower 2 inches of the appliance or pouch with toilet tissue.

9. Uncuff edge of appliance or pouch and apply clip or clamp, or secure Velcro closure. Ensure the curve of the clamp follows the curve of the patient’s body. Remove
gloves. Assist patient to a comfortable position.

10. If appliance is not to be changed, remove additional PPE, if used. Perform hand hygiene.

Changing an Appliance
11. Place a disposable pad on the work surface. Set up the wash basin with warm water and the rest of the supplies. Place a trash bag within reach.

12. Put on clean gloves. Place waterproof pad under the patient at the stoma site. Empty the appliance as described previously.

13. Gently remove pouch faceplate from skin by pushing skin from appliance rather than pulling appliance from skin. Start at the top of the appliance, while keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping with the remover wipe.

14. Place the appliance in the trash bag, if disposable. If reusable, set aside to wash in lukewarm soap and water and allow to air dry after the new appliance is in place.

15. Use toilet tissue to remove any excess stool from stoma. Cover stoma with gauze pad. Clean skin around stoma with mild soap and water or a cleansing agent and a washcloth. Remove all old adhesive from skin; use an adhesive remover, as necessary. Do not apply lotion to peristomal area.

16. Gently pat area dry. Make sure skin around stoma is thoroughly dry. Assess stoma and condition of surrounding skin.

17. Apply skin protectant to a 2-inch (5 cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds.

18. Lift the gauze squares for a moment and measure the stoma opening, using the measurement guide. Replace the gauze. Trace the same-size opening on the back center of the appliance. Cut the opening 1/8 inch larger than the stoma size.

19. Remove the backing from the appliance. Quickly remove the gauze squares and ease the appliance over the stoma. Gently press onto the skin while smoothing over the
surface. Apply gentle pressure to appliance for 5 minutes.

20. Close bottom of appliance or pouch by folding the end upward and using the clamp or clip that comes with the product, or secure Velcro closure. Ensure the curve of the clamp follows the curve of the patient’s body.

21. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

22. Put on clean gloves. Remove or discard equipment and assess patient’s response to procedure.

23. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Applying a Fecal Incontinence Pouch

Goal: The patient expels feces into the pouch and maintains intact perianal skin.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip.

6. Put on nonsterile gloves. Cleanse perianal area. Pat dry thoroughly.

7. Trim perianal hair with scissors, if needed.

8. Apply the skin protectant or barrier and allow it to dry.

9. Remove paper backing from adhesive of pouch.

10. With nondominant hand, separate buttocks. Apply fecal pouch to anal area with dominant hand, ensuring that opening of bag is over anus.

11. Release buttocks. Attach connector of fecal incontinence pouch to urinary drainage bag. Hang drainage bag below patient.

12. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Ensure that the patient is covered.

13. Raise side rail. Lower bed height and adjust head of bed to a comfortable position.

14. Remove additional PPE, if used. Perform hand hygiene.
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Digital Removal of Stool

Goal: The patient expels feces with assistance and is free from trauma with minimal patient discomfort.

1. Verify the order. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and whyyou are going to do it to the patient. Discuss signs and symptoms of a slow heart rate. Instruct patient to alert you if any of these symptoms are felt during the procedure. Have a bedpan ready for use.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’
position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the
patient’s hip.

6. Put on nonsterile gloves.

7. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus.

8. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct patient to bear down, if possible, while extracting feces to ease in removal. Place extracted stool in bedpan.

9. Remove impaction at intervals if it is severe. Instruct patient to alert you if he or she begins to feel lightheaded or nauseated. If patient reports either symptom, stop removal and assess patient.

10. Put on clean gloves. Assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. If patient is able, offer sitz bath.

11. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Ensure that the patient is covered.

12. Raise side rail. Lower bed height and adjust head of bed to a comfortable position.

13. Remove additional PPE, if used. Perform hand hygiene.
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Administering a Retention Enema

Goal: The patient retains the solution for the prescribed, appropriate length of time and experiences the expected therapeutic effect of the solution.

1. Verify the order for the enema. Bring necessary equipment to the bedside stand or overbed table. Warm the solution to body temperature in a bowl of warm water.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Have a bedpan, commode, or nearby bathroom ready for use.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip.

6. Put on nonsterile gloves.

7. Remove cap of prepackaged enema solution. Apply a generous amount of lubricant to the tube.

8. Lift buttock to expose anus. Slowly and gently insert rectal tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an angle pointing toward the umbilicus. Ask patient to take several deep breaths.

9. If resistance is met while inserting the tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of tube.

10. Slowly squeeze enema container, emptying entire contents.

11. Remove container while keeping it compressed. Have paper towel ready to receive tube as it is withdrawn.

12. Instruct patient to retain enema solution for at least 30 minutes or as indicated, per manufacturer’s direction.

13. Remove your gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry and ensure that the patient is covered.

14. Raise side rail. Lower bed height and adjust head of bed to a comfortable position.

15. Remove additional PPE, if used. Perform hand hygiene.

16. If the patient has a strong urge to dispel the solution, place him or her in a sitting position on bedpan or assist to commodeor bathroom. Stay with patient or have call bell readily accessible.

17. Remind patient not to flush commode before you inspect results of enema, if used for bowel evacuation. Record character of stool, as appropriate, and patient’s reaction to enema.

18. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. Remove gloves.

19. Leave patient clean and comfortable. Care for equipment properly.

20. Perform hand hygiene.
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Administering a Small Volume Cleansing Enema

Goal: The patient expels feces and reports a decrease in pain and discomfort.

1. Verify the order for the enema. Bring necessary equipment to the bedside stand or overbed table. Warm the solution to body temperature in a bowl of warm water.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Discuss where the patient will defecate. Have a bedpan, commode, or nearby bathroom ready for use.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip.

6. Put on nonsterile gloves.

7. Remove the cap and generously lubricate end of rectal tube 2 to 3 inches (5 to 7 cm).

8. Lift buttock to expose anus. Slowly and gently insert the rectal tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not bladder. Do not force entry of the tube. Ask patient to take several deep breaths.

9. Compress the container with your hands. Roll the end up on itself, toward the rectal tip. Administer all the solution in the container.

10. After solution has been given, remove tube, keeping the container compressed. Have paper towel ready to receive tube as it is withdrawn. Encourage the patient to hold the solution until the urge to defecate is strong, usually in about 5 to 15 minutes.

11. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Ensure that the patient is covered.

12. Raise side rail. Lower bed height and adjust head of bed to a comfortable position.

13. Remove additional PPE, if used. Perform hand hygiene.

14. When patient has a strong urge to defecate, place him or her in a sitting position on a bedpan or assist to commode or bathroom. Stay with patient or have call bell readily accessible.

15. Remind patient not to flush the commode before you inspect the results of the enema.

16. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. Remove gloves.

17. Leave the patient clean and comfortable. Care for equipment properly.

18. Perform hand hygiene.
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Administering a Large-Volume Cleansing Enema

Goal: The patient expels feces and is free from injury with minimal discomfort.

1. Verify the order for the enema. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Discuss where the patient will defecate. Have a bedpan, commode, or nearby bathroom ready for use.

5. Warm solution in amount ordered, and check temperature with a bath thermometer, if available. If bath thermometer is not available, warm to room temperature or slightly higher, and test on inner wrist. If tap water is used, adjust temperature as it flows from faucet.

6. Add enema solution to container. Release clamp and allow fluid to progress through tube before reclamping.

7. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip.

8. Put on nonsterile gloves.

9. Elevate solution so that it is no higher than 18 inches (45 cm) above level of anus. Plan to give the solution slowly over a period of 5 to 10 minutes. Hang the
container on an IV pole or hold it at the proper height.

10. Generously lubricate end of rectal tube 2 to 3 inches (5 to 7 cm). A disposable enema set may have a prelubricated rectal tube.

11. Lift buttock to expose anus. Slowly and gently insert the enema tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not bladder. Ask patient to take several deep breaths.

12. If resistance is met while inserting tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of the tube. Ask patient to take several deep breaths.

13. Introduce solution slowly over a period of 5 to 10 minutes. Hold tubing all the time that solution is being instilled.

14. Clamp tubing or lower container if patient has desire to defecate or cramping occurs. Instruct the patient to take small, fast breaths or to pant.

15. After solution has been given, clamp tubing and remove tube. Have paper towel ready to receive tube as it is withdrawn.

16. Return the patient to a comfortable position. Encourage the patient to hold the solution until the urge to defecate is strong, usually in about 5 to 15 minutes. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered.

17. Raise side rail. Lower bed height and adjust head of bed to a comfortable position.

18. Remove additional PPE, if used. Perform hand hygiene.

19. When patient has a strong urge to defecate, place him or her in a sitting position on a bedpan or assist to commode or bathroom. Offer toilet tissues, if not in patient’s reach. Stay with patient or have call bell readily accessible.

20. Remind patient not to flush the commode before you inspect results of enema.

21. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. Remove gloves.

22. Leave the patient clean and comfortable. Care for equipment properly.

23. Perform hand hygiene.
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Caring for a Hemodialysis Access (Arteriovenous Fistula or Graft)

Goal: The graft or fistula remains patent; the patient verbalizes appropriate care measures and observations to be made, and demonstrates care measures.

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient.

3. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do, and why you are going to do it, to the patient.

4. Inspect area over access site for any redness, warmth, tenderness, or blemishes. Palpate over access site, feeling for a thrill or vibration. Palpate pulses distal to the site. Auscultate over access site with bell of stethoscope, listening for a bruit or vibration.

5. Ensure that a sign is placed over head of bed informing the healthcare team which arm is affected. Do not measure blood pressure, perform a venipuncture, or start an IV on the access arm.

6. Instruct the patient not to sleep with the arm with the access site under head or body.

7. Instruct patient not to lift heavy objects with, or put pressure on, the arm with the access site. Advise the patient not to carry heavy bags (including purses) on the shoulder of that arm.

8. Remove PPE, if used. Perform hand hygiene.
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Caring for a Peritoneal Dialysis Catheter

Goal: The peritoneal dialysis catheter dressing change is completed using aseptic technique without trauma to the site or patient; the site is clean, dry, and intact, without evidence of inflammation or infection.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Encourage the patient to observe or participate if possible.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Assist the patient to a supine position. Expose the abdomen, draping the patient’s chest with the bath blanket, exposing only the catheter site.

6. Put on unsterile gloves. Put on one of the facemasks; have patient put on the other mask.

7. Gently remove old dressing, noting odor, amount and color of drainage, leakage, and condition of skin around the catheter. Discard dressing in appropriate container.

8. Remove gloves and discard. Set up sterile field. Open packages. Using aseptic technique, place two sterile gauze squares in basin with antimicrobial agent. Leave two sterile gauze squares opened on sterile field. Alternately (based on facility’s policy), place sterile antimicrobial swabs on the sterile field. Place sterile applicator on field. Squeeze a small amount of the topical antibiotic on one of the gauze squares on the sterile field.

9. Put on sterile gloves. Pick up dialysis catheter with nondominant hand. With the antimicrobial-soaked gauze/swab, cleanse the skin around the exit site using a
circular motion, starting at the exit site and then slowly going outward 3 to 4 inches. Gently remove crusted scabs, if necessary.

10. Continue to hold catheter with nondominant hand. After skin has dried, clean the catheter with an antimicrobialsoaked gauze, beginning at exit site, going around
catheter, and then moving up to end of catheter. Gently remove crusted secretions on the tube, if necessary.

11. Using the sterile applicator, apply the topical antibiotic to the catheter exit site, if prescribed.

12. Place sterile drain sponge around exit site. Then place a 4 4 gauze over exit site. Remove your gloves and secure edges of gauze pad with tape. Some institutions recommend placing a transparent dressing over the gauze pads instead of tape. Remove masks.

13. Coil the exposed length of tubing and secure to the dressing or the patient’s abdomen with tape.

14. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

15. Put on clean gloves. Remove or discard equipment and assess the patient’s response to the procedure.

16. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Caring for a Suprapubic Urinary Catheter

Goal: The patient's skin remains clean, dry, intact, and without evidence of irritation or breakdown; and the patient verbalizes an understanding of the purpose for, and care of the catheter, as appropriate.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do, and why you are going to do it, to the patient. Encourage the patient to observe or participate, if possible.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Assist patient to a supine position. Place waterproof pad under the patient at the stoma site.

6. Put on clean gloves. Gently remove old dressing, if one is in place. Place dressing in trash bag. Remove gloves. Perform hand hygiene.

7. Assess the insertion site and surrounding skin.

8. Wet washcloth with warm water and apply skin cleanser. Gently cleanse around suprapubic exit site. Remove any encrustations. If this is a new suprapubic catheter, use sterile cotton-tipped applicators and sterile saline to clean the site until the incision has healed. Moisten the applicators with the saline and clean in circular motion from the insertion site outward.

9. Rinse area of all cleanser. Pat dry.

10. If the exit site has been draining, place small drain sponge around the catheter to absorb any drainage. Be prepared to change this sponge throughout the day, depending on the amount of drainage. Do not cut a 4 4 gauze to make a drain sponge.

11. Remove gloves. Form a loop in tubing and anchor the tubing on the patient’s abdomen.

12. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

13. Put on clean gloves. Remove or discard equipment and assess the patient’s response to the procedure.

14. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Emptying and Changing a Stoma Appliance on an Ileal Conduit

Goal: The stoma appliance is applied correctly to the skin to allow urine to drain freely.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Encourage patient to observe or participate, if possible.

5. Assist patient to a comfortable sitting or lying position in bed or a standing or sitting position in the bathroom. If the patient is in bed, adjust the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Place waterproof pad under the patient at the stoma site.

Emptying the Appliance:
6. Put on gloves. Hold end of appliance over a bedpan, toilet, or measuring device. Remove the end cap from the spout. Open spout and empty contents into the bedpan, toilet, or measuring device.

7. Close the spout. Wipe the spout with toilet tissue. Replace the cap.

8. Remove equipment. Remove gloves. Assist patient to comfortable position.

9. If appliance is not to be changed, place bed in lowest position. Remove additional PPE, if used. Perform hand hygiene.

Changing the Appliance:
10. Place a disposable waterproof pad on the overbed table or other work area. Set up the washbasin with warm water and the rest of the supplies. Place a trash bag within reach.

11. Put on clean gloves. Place waterproof pad under the patient at the stoma site. Empty the appliance if necessary as described in steps 6–8.

12. Gently remove appliance faceplate from skin by pushing skin from appliance rather than pulling appliance from skin. Start at the top of the appliance, while keeping the skin taut. Apply a silicone-based adhesive remover by spraying or wiping with the remover wipe.

13. Place the appliance in the trash bag, if disposable. If reusable, set aside to wash in lukewarm soap and water and allow to air dry after the new appliance is in place.

14. Clean skin around stoma with mild soap and water or a cleansing agent and a washcloth. Remove all old adhesive from skin; additional adhesive remover may be used. Do not apply lotion to peristomal area.

15. Gently pat area dry. Make sure skin around stoma is thoroughly dry. Assess stoma and condition of surrounding skin.

16. Place one or two gauze squares over stoma opening.

17. Apply skin protectant to a 2-inch (5-cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds.

18. Lift the gauze squares for a moment and measure the stoma opening, using the measurement guide. Replace the gauze. Trace the same size opening on the back center of the appliance. Cut the opening 1/8 inch larger than the stoma size. Check that the spout is closed and the end cap is in place.

19. Remove the backing from the appliance. Quickly remove the gauze squares and discard appropriately; ease the appliance over the stoma. Gently press onto the skin while smoothing over the surface. Apply gentle pressure to the appliance for a few minutes.

20. Secure optional belt to appliance and around patient.

21. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

22. Put on clean gloves. Remove or discard any remaining equipment and assess patient’s response to procedure.

23. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Administering a Continuous Closed Bladder Irrigation

Goal: The patient exhibits free-flowing urine through the catheter.

1. Confirm the order for catheter irrigation in the medical record. Calculate the drip rate via gravity infusion for the prescribed infusion rate.

2. Bring necessary equipment to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around the bed and close the door to the room, if possible. Discuss the procedure with patient.

6. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009).

7. Empty the catheter drainage bag and measure the amount of urine, noting the amount and characteristics of the urine.

8. Assist patient to comfortable position and expose the irrigation port on the catheter setup. Place waterproof pad under the catheter and aspiration port.

9. Prepare sterile irrigation bag for use as directed by manufacturer. Clearly label the solution as ‘Bladder Irrigant.’ Include the date and time on the label. Hang bag on IV pole 2.5 to 3 feet above the level of the patient’s bladder. Secure tubing clamp and insert sterile tubing with drip chamber to container using aseptic technique. Release clamp and remove protective cover on end of tubing without contaminating it. Allow solution to flush tubing and remove air. Clamp tubing and replace end cover.

10. Put on gloves. Cleanse the irrigation port on the catheter with an alcohol swab. Using aseptic technique, attach irrigation tubing to irrigation port of three-way
indwelling catheter.

11. Check the drainage tubing to make sure clamp, if present, is open.

12. Release clamp on irrigation tubing and regulate flow at determined drip rate, according to the ordered rate. If the bladder irrigation is to be done with a medicated solution, use an electronic infusion device to regulate the flow.

13. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

14. Assess patient’s response to the procedure, and quality and amount of drainage.

15. Remove equipment. Remove gloves and additional PPE, if used. Perform hand hygiene.

16. As irrigation fluid container nears empty, clamp the administration tubing. Do not allow drip chamber to empty. Disconnect empty bag and attach a new full irrigation solution bag.

17. Put on gloves and empty drainage collection bag as each new container is hung and recorded.
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Performing Intermittent Closed Catheter Irrigation

Goal: The patient exhibits the free flow of urine through the catheter.

1. Confirm the order for catheter irrigation in the medical record.

2. Bring necessary equipment to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with patient.

6. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009).

7. Put on gloves. Empty the catheter drainage bag and measure the amount of urine, noting the amount and characteristics of the urine. Remove gloves.

8. Assist patient to comfortable position and expose access port on catheter setup. Place waterproof pad under catheter and aspiration port. Remove catheter from device or tape anchoring catheter to the patient.

9. Open supplies, using aseptic technique. Pour sterile solution into sterile basin. Aspirate the prescribed amount of irrigant (usually 30 to 60 mL) into sterile syringe. Put on gloves.

10. Cleanse the access port on catheter with antimicrobial swab.

11. Clamp or fold catheter tubing below the access port.

12. Attach the syringe to the access port on the catheter using a twisting motion. Gently instill solution into catheter.

13. Remove syringe from access port. Unclamp or unfold tubing and allow irrigant and urine to flow into the drainage bag. Repeat procedure, as necessary.

14. Remove gloves. Secure catheter tubing to the patient’s inner thigh or lower abdomen (if a male patient) with anchoring device or tape. Leave some slack in the catheter for leg movement.

15. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

16. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with catheter or drainage bag.

17. Remove equipment and discard syringe in appropriate receptacle. Remove gloves and additional PPE, if used. Perform hand hygiene.

18. Assess patient’s response to the procedure and the quality and amount of drainage after the irrigation.
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Removing an Indwelling Catheter

Goal: The catheter is removed without difficulty and with minimal patient discomfort.

1. Confirm the order for catheter removal in the medical record.

2. Bring necessary equipment to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure.

6. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are righthanded, patient’s left side if you are left-handed.

7. Position the patient as for catheter insertion. Drape the patient so that only the area around the catheter is exposed. Slide waterproof pad between the female patient’s legs or over the male patient’s thighs.

8. Remove the leg strap, tape, or other device used to secure the catheter to the patient’s thigh or abdomen.

9. Insert the syringe into the balloon inflation port. Allow water to come back by gravity (Mercer Smith, 2003). Alternately, aspirate the entire amount of sterile water used to inflate the balloon. Refer to manufacturer’s instructions for deflation. Do not cut the inflation port.

10. Ask the patient to take several slow deep breaths. Slowly and gently remove the catheter. Place it on the waterproof pad and wrap it in the pad.

11. Wash and dry the perineal area, as needed.

12. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

13. Put on clean gloves. Remove equipment and dispose of it according to facility policy. Note characteristics and amount of urine in drainage bag.

14. Remove gloves and additional PPE, if used. Perform hand hygiene.




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Catheterizing the Male Urinary Bladder

Goal: The patient’s urinary elimination is maintained, with a urine output of at least 30 mL/hour, and the patient’s bladder is not distended.

1. Review chart for any limitations in physical activity. Confirm the medical order for indwelling catheter insertion.

2. Bring catheter kit and other necessary equipment to the bedside. Obtain assistance from another staff member, if necessary.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess patient’s ability to assist with the procedure. Ask the patient if he has any allergies, especially to latex or iodine.

6. Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach.

7. Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are righthanded, patient’s left side if you are left-handed.

8. Position the patient on his back with thighs slightly apart. Drape the patient so that only the area around the penis is exposed. Slide waterproof pad under patient.

9. Put on clean gloves. Clean the genital area with washcloth, skin cleanser, and warm water. Clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area. Rinse and dry. Remove gloves. Perform hand hygiene again.

10. Prepare urine drainage setup if a separate urine collection system is to be used. Secure to bed frame according to manufacturer’s directions.

11. Open sterile catheterization tray on a clean overbed table, using sterile technique.

12. Put on sterile gloves. Open sterile drape and place on patient’s thighs. Place fenestrated drape with opening over penis.

13. Place catheter set on or next to patient’s legs on sterile drape.

14. Open all the supplies. Fluff cotton balls in tray before pouring antiseptic solution over them. Alternately, open package of antiseptic swabs. Open specimen container if specimen is to be obtained. Remove cap from syringe prefilled with lubricant.

15. Place drainage end of catheter in receptacle. If the catheter is preattached to sterile tubing and drainage container (closed drainage system), position catheter and setup within easy reach on sterile field. Ensure that clamp on drainage bag is closed.

16. Lift penis with nondominant hand. Retract foreskin in uncircumcised patient. Be prepared to keep this hand in this position until catheter is inserted and urine is flowing well and continuously. Using the dominant hand and the forceps, pick up a cotton ball or antiseptic swab. Using a circular motion, clean the penis, moving from the meatus down the glans of the penis. Repeat this cleansing motion two more times, using a new cotton ball/swab each time. Discard each cotton ball/swab after one use.

17. Hold penis with slight upward tension and perpendicular to patient’s body. Use the dominant hand to pick up the lubricant syringe. Gently insert tip of syringe with lubricant into urethra and instill the 10 mL of lubricant (Society of Urologic Nurses and Associates, 2005c).

18. Use the dominant hand to pick up the catheter and hold it an inch or two from the tip. Ask the patient to bear down as if voiding. Insert catheter tip into meatus. Ask the patient to take deep breaths. Advance the catheter to the bifurcation or “Y” level of the ports. Do not use force to introduce the catheter. If the catheter resists entry, ask patient to breathe deeply and rotate catheter slightly.

19. Hold the catheter securely at the meatus with your nondominant hand. Use your dominant hand to inflate the catheter balloon. Inject the entire volume of sterile water supplied in the prefilled syringe. Once the balloon is inflated, the catheter may be gently pulled back into place. Replace foreskin over catheter. Lower penis.

20. Pull gently on catheter after balloon is inflated to feel resistance.

21. Attach catheter to drainage system, if necessary.

22. Remove equipment and dispose of it according to facility policy. Discard syringe in sharps container. Wash and dry the perineal area as needed.

23. Remove gloves. Secure catheter tubing to the patient’s inner thigh or lower abdomen (with the penis directed toward the patient’s chest) with Velcro leg strap or tape. Leave some slack in catheter for leg movement.

24. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

25. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with catheter or drainage bag.

26. Put on clean gloves. Obtain urine specimen immediately, if needed, from drainage bag. Label specimen. Send urine specimen to the laboratory promptly or refrigerate it.

27. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Catheterizing the Female Urinary Bladder

Goal: The patient’s urinary elimination is maintained, with a urine output of at least 30 mL/hour, and the patient’s bladder is not distended.

1. Review the patient’s chart for any limitations in physical activity. Confirm the medical order for indwelling catheter insertion.

2. Bring the catheter kit and other necessary equipment to the bedside. Obtain assistance from another staff member, if necessary.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure. Ask the patient if she has any allergies, especially to latex or iodine.

6. Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach.

7. Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are righthanded, patient’s left side if you are left-handed.

8. Assist the patient to a dorsal recumbent position with knees flexed, feet about 2 feet apart, with her legs abducted. Drape patient. Alternately, the Sims’, or lateral, position can be used. Place the patient’s buttocks near the edge of the bed with her shoulders at the opposite edge and her knees drawn toward her chest. Allow the patient to lie on either side, depending on which position is easiest for the nurse and best for the patient’s comfort. Slide waterproof pad under patient.

9. Put on clean gloves. Clean the perineal area with washcloth, skin cleanser, and warm water, using a different corner of the washcloth with each stroke. Wipe from above orifice downward toward sacrum (front to back). Rinse and dry. Remove gloves. Perform hand hygiene again.

10. Prepare urine drainage setup if a separate urine collection system is to be used. Secure to bed frame according to manufacturer’s directions.

11. Open sterile catheterization tray on a clean overbed table using sterile technique.

12. Put on sterile gloves. Grasp upper corners of drape and unfold drape without touching unsterile areas. Fold back a corner on each side to make a cuff over gloved hands. Ask patient to lift her buttocks and slide sterile drape under her with gloves protected by cuff.

13. Based on facility policy, position the fenestrated sterile drape. Place a fenestrated sterile drape over the perineal area, exposing the labia.

14. Place sterile tray on drape between patient’s thighs.

15. Open all the supplies. Fluff cotton balls in tray before pouring antiseptic solution over them. Alternately, open package of antiseptic swabs. Open specimen container if specimen is to be obtained.

16. Lubricate 1 to 2 inches of catheter tip.

17. With thumb and one finger of nondominant hand, spread labia and identify meatus. Be prepared to maintain separation of labia with one hand until catheter is inserted and urine is flowing well and continuously. If the patient is in the side-lying position, lift the upper buttock and labia to expose the urinary meatus.

18. Use the dominant hand to pick up a cotton ball or antiseptic swab. Clean one labial fold, top to bottom (from above the meatus down toward the rectum), then discard the cotton ball. Using a new cotton ball/swab for each stroke, continue to clean the other labial fold, then directly over the meatus.

19. With your uncontaminated, dominant hand, place the drainage end of the catheter in receptacle. If the catheter is preattached to sterile tubing and drainage container (closed drainage system), position catheter and setup within easy reach on sterile field. Ensure that clamp on drainage bag is closed.

20. Using your dominant hand, hold the catheter 2 to 3 inches from the tip and insert slowly into the urethra. Advance the catheter until there is a return of urine (approximately 2 to 3 inches [4.8 to 7.2 cm]). Once urine drains, advance catheter another 2 to 3 inches (4.8 to 7.2 cm). Do not force catheter through urethra into bladder. Ask patient to breathe deeply, and rotate catheter gently if slight resistance is met as catheter reaches external sphincter.

21. Hold the catheter securely at the meatus with your nondominant hand. Use your dominant hand to inflate the catheter balloon. Inject entire volume of sterile water supplied in prefilled syringe.

22. Pull gently on catheter after balloon is inflated to feel resistance.

23. Attach catheter to drainage system if not already preattached.

24. Remove equipment and dispose of it according to facility policy. Discard syringe in sharps container. Wash and dry the perineal area, as needed.

25. Remove gloves. Secure catheter tubing to the patient’s inner thigh with Velcro leg strap or tape. Leave some slack in catheter for leg movement.

26. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

27. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with catheter or drainage bag.

28. Put on clean gloves. Obtain urine specimen immediately, if needed, from drainage bag. Label specimen. Send urine specimen to the laboratory promptly or refrigerate it.

29. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Applying an External Condom Catheter

Goal: The patient's urinary elimination is maintained, with a urine output of at least 30 mL/hour, and the bladder is not distended.

1. Bring necessary equipment to the bedside.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with patient. Ask the patient if he has any allergies, especially to latex.

5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are righthanded, or on patient’s left side if you are left-handed.

6. Prepare urinary drainage setup or reusable leg bag for attachment to condom sheath.

7. Position patient on his back with thighs slightly apart. Drape patient so that only the area around the penis is exposed. Slide waterproof pad under patient.

8. Put on disposable gloves. Trim any long pubic hair that is in contact with penis.

9. Clean the genital area with washcloth, skin cleanser, and warm water. If patient is uncircumcised, retract foreskin and clean glans of penis. Replace foreskin. Clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area. Rinse and dry. Remove gloves. Perform hand hygiene again.

10. Apply skin protectant to penis and allow to dry.

11. Roll condom sheath outward onto itself. Grasp penis firmly with nondominant hand. Apply condom sheath by rolling it onto penis with dominant hand. Leave 1 to
2 inches (2.5 to 5 cm) of space between tip of penis and end of condom sheath.

12. Apply pressure to sheath at the base of penis for 10 to 15 seconds.

13. Connect condom sheath to drainage setup. Avoid kinking or twisting drainage tubing.

14. Remove gloves. Secure drainage tubing to the patient’s inner thigh with Velcro leg strap or tape. Leave some slack in tubing for leg movement.

15. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.

16. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with the drainage bag.

17. Remove equipment. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Assessing Bladder Volume Using an Ultrasound Bladder Scanner

Goal: The volume of urine in the bladder is accurately measured.

1. Review the patient’s chart for any limitations in physical activity.

2. Bring the bladder scanner and other necessary equipment to the bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences.

6. Adjust the bed to a comfortable working height; usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Place the patient in a supine position. Drape patient. Stand on the patient’s right side if you are righthanded, patient’s left side if you are left-handed.

7. Put on clean gloves.

8. Press the ON button. Wait until the device warms up. Press the SCAN button to turn on the scanning screen.

9. Press the appropriate gender button. The appropriate icon for male or female will appear on the screen.

10. Clean the scanner head with the appropriate cleaner.

11. Gently palpate the patient’s symphysis pubis. Place a generous amount of ultrasound gel or gel pad midline on the patient’s abdomen, about 1 to 1.5 inches above the symphysis pubis (anterior midline junction of pubic bones).

12. Place the scanner head on the gel or gel pad, with the directional icon on the scanner head toward the patient’s head. Aim the scanner head toward the bladder (point the scanner head slightly downward toward the coccyx) (Patraca, 2005). Press and release the scan button.

13. Observe the image on the scanner screen. Adjust the scanner head to center the bladder image on the crossbars.

14. Press and hold the DONE button until it beeps. Read the volume measurement on the screen. Print the results, if required, by pressing PRINT.

15. Use a washcloth or paper towel to remove remaining gel from the patient’s skin. Alternately, gently remove gel pad from patient’s skin. Return the patient to a comfortable position. Remove your gloves and ensure that the patient is covered.

16. Lower bed height and adjust head of bed to a comfortable position. Reattach call bell, if necessary.

17. Remove additional PPE, if used. Perform hand hygiene.
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Assisting With the Use of a Bedside Commode

Goal: The patient is able to void with assistance.

1. Review the patient’s chart for any limitations in physical activity.

2. Bring the commode and other necessary equipment to the bedside. Obtain assistance for patient transfer from another staff member, if necessary.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close the curtains around the bed and close the door to the room, if possible. Discuss procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences.

6. Place the commode close to, and parallel with, the bed. Raise or remove the seat cover.

7. Assist the patient to a standing position and then help the patient pivot to the commode. While bracing one commode leg with your foot, ask the patient to place his or her hands one at a time on the armrests. Assist the patient to lower himself/herself slowly onto the commode seat.

8. Cover the patient with a blanket. Place call bell and toilet tissue within easy reach. Leave patient if it is safe to do so.

Assisting Patient Off Commode:
9. Perform hand hygiene. Put on gloves and additional PPE, as indicated.

10. Assist the patient to a standing position. If patient needs assistance with hygiene, wrap toilet tissue around your hand several times, and wipe patient clean, using one stroke from the pubic area toward the anal area. Discard tissue in an appropriate receptacle, according to facility policy, and continue with additional tissue until patient is clean.

11. Do not place toilet tissue in the commode if a specimen is required or if output is being recorded. Replace or lower the seat cover.

12. Remove your gloves. Return the patient to the bed or chair. If the patient returns to the bed, raise side rails, as appropriate. Ensure that the patient is covered and call bell is readily within reach.

13. Offer patient supplies to wash and dry his or her hands, assisting as necessary.

14. Put on clean gloves. Empty and clean the commode, measuring urine in graduated container, as necessary.

15. Remove gloves and additional PPE, if used. Perform hand hygiene.
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Assisting With the Use of a Urinal

Goal: The patient is able to void with assistance.

1. Review the patient’s chart for any limitations in physical activity.

2. Bring urinal and other necessary equipment to the bedside stand or overbed table.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close the curtains around the bed and close the door to the room, if possible. Discuss procedure with patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences.

6. Put on gloves.

7. Assist the patient to an appropriate position, as necessary: standing at the bedside, lying on one side or back, sitting in bed with the head elevated, or sitting on the side of the bed.

8. If the patient remains in the bed, fold the linens just enough to allow for proper placement of the urinal.

9. If the patient is not standing, have him spread his legs slightly. Hold the urinal close to the penis and position the penis completely within the urinal. Keep the bottom of the urinal lower than the penis. If necessary, assist the patient to hold the urinal in place.

10. Cover the patient with the bed linens.

11. Place call bell and toilet tissue within easy reach. Have a receptacle, such as plastic trash bag, handy for discarding tissue. Ensure the bed is in the lowest position. Leave patient if it is safe to do so. Use side rails appropriately.

12. Remove gloves and additional PPE, if used. Perform hand hygiene. Removing the Urinal

13. Perform hand hygiene. Put on gloves and additional PPE, as indicated.

14. Pull back the patient’s bed linens just enough to remove the urinal. Remove the urinal. Cover the open end of the urinal. Place on the bedside chair. If patient needs assistance with hygiene, wrap tissue around the hand several times, and wipe patient clean. Place tissue in receptacle.

15. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered.

16. Ensure patient call bell is in reach.

17. Offer patient supplies to wash and dry his hands, assisting as necessary.

18. Put on clean gloves. Empty and clean the urinal, measuring urine in graduated container, as necessary. Discard trash receptacle with used toilet paper per facility policy.

19. Remove gloves and additional PPE, if used, and perform hand hygiene.
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Assisting With the Use of a Bedpan

Goal: The patient is able to void with assistance.

1. Review the patient’s chart for any limitations in physical activity. (See Skill Variation: Assisting With Use of a Bedpan When the Patient Has Limited Movement.)

2. Bring bedpan and other necessary equipment to the bedside stand or overbed table.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences.

6. Unless contraindicated, apply powder to the rim of the bedpan. Place bedpan and cover on chair next to bed. Put on gloves.

7. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Place the patient in a supine position, with the head of the bed elevated about 30 degrees, unless contraindicated.

8. Fold top linen back just enough to allow placement of bedpan. If there is no waterproof pad on the bed and time allows, consider placing a waterproof pad under patient’s buttocks before placing bedpan.

9. Ask the patient to bend the knees. Have the patient lift his or her hips upward. Assist patient, if necessary, by placing your hand that is closest to the patient palm up, under the lower back, and assist with lifting. Slip the bedpan into place with other hand.

10. Ensure that bedpan is in proper position and patient’s buttocks are resting on the rounded shelf of the regular bedpan or the shallow rim of the fracture bedpan.

11. Raise head of bed as near to sitting position as tolerated, unless contraindicated. Cover the patient with bed linens.

12. Place call bell and toilet tissue within easy reach. Place the bed in the lowest position. Leave patient if it is safe to do so. Use side rails appropriately.

13. Remove gloves and additional PPE, if used. Perform hand hygiene.

Removing the Bedpan:
14. Perform hand hygiene and put on gloves and additional PPE, as indicated. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8
Patient Safety Center, 2009). Have a receptacle, such as plastic trash bag, handy for discarding tissue.

15. Lower the head of the bed, if necessary, to about 30 degrees. Remove bedpan in the same manner in which it was offered, being careful to hold it steady. Ask the patient to bend the knees and lift the buttocks up from the bedpan. Assist patient, if necessary, by placing your hand that is closest to the patient palm up, under the lower back, and assist with lifting. Place the bedpan on the bedside chair and cover it.

16. If patient needs assistance with hygiene, wrap tissue around the hand several times, and wipe patient clean, using one stroke from the pubic area toward the anal area. Discard tissue, and use more until patient is clean. Place patient on his or her side and spread buttocks to clean anal area.

17. Do not place toilet tissue in the bedpan if a specimen is required or if output is being recorded. Place toilet tissue in appropriate receptacle.

18. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Replace or remove pad under the patient, as necessary. Remove your gloves and ensure that the patient is covered.

19. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Reattach call bell.

20. Offer patient supplies to wash and dry his or her hands, assisting as necessary.

21. Put on clean gloves. Empty and clean the bedpan, measuring urine in graduated container, as necessary. Discard trash receptacle with used toilet paper per facility policy.

22. Remove additional PPE, if used. Perform hand hygiene.
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Caring for a Gastrostomy Tube

Goal: The patient ingests an adequate diet and exhibits no signs and symptoms of irritation, excoriation, or infection at the tube insertion site.

1. Assemble equipment. Verify the medical order or facility policy and procedure regarding site care.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed.

5. Assess patient for presence of pain at the tube insertion site. If pain is present, offer patient analgesic medication per physician’s order and wait for medication absorption before beginning insertion site care.

6. Pull the patient’s bedside curtain. Raise bed to a comfortable working position, usually elbow height of the caregiver (VISN 8, 2009).

7. Put on gloves. If gastrostomy tube is new and still has sutures holding it in place, dip cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement except to clean the area. If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto washcloth. Gently cleanse around the insertion, removing any crust or drainage. Rinse site, removing all soap.

8. Pat skin around insertion site dry.

9. If the sutures have been removed, gently rotate the guard or external bumper 90 degrees at least once a day. Assess that the guard or external bumper is not digging into the surrounding skin. Avoid placing any tension on the feeding tube.

10. Leave the site open to air unless there is drainage. If drainage is present, place one thickness of precut gauze pad or drain sponge under the external bumper and
change as needed to keep the area dry. Use a skin protectant or substance such as zinc oxide to prevent skin breakdown.

11. Remove gloves. Lower the bed and assist the patient to a position of comfort as needed.

12. Remove additional PPE, if used. Perform hand hygiene.
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Removing a Nasogastric Tube

Goal: The tube is removed with minimal discomfort to the patient, and the patient maintains an adequate nutritional intake.

1. Check medical order for removal of NG tube.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Explain the procedure to the patient and why this intervention is warranted. Describe that it will entail a quick few moments of discomfort. Perform key abdominal assessments as described above.

5. Pull the patient’s bedside curtain. Raise bed to a comfortable working position, usually elbow height of the caregiver (VISN 8, 2009). Assist the patient into a 30- to 45-degree position. Place towel or disposable pad across patient’s chest. Give tissues and emesis basin to patient.

6. Put on gloves. Discontinue suction and separate tube from suction. Unpin tube from patient’s gown and carefully remove adhesive tape from patient’s nose.

7. Check placement (as outlined in Skill 11-2) and attach syringe and flush with 10 mL of water or normal saline solution (optional) or clear with 30 to 50 mL of air.

8. Clamp tube with fingers by doubling tube on itself. Instruct patient to take a deep breath and hold it. Quickly and carefully remove tube while patient holds breath. Coil the tube in the disposable pad as you remove from the patient.

9. Dispose of tube per agency policy. Remove gloves and place in bag. Perform hand hygiene.

10. Offer mouth care to patient and facial tissue to blow nose. Lower the bed and assist the patient to a position of comfort as needed.

11. Remove equipment and raise side rail and lower bed.

12. Put on gloves and measure the amount of nasogastric drainage in the collection device and record on output flow record, subtracting irrigant fluids if necessary. Add solidifying agent to nasogastric drainage according to hospital policy.

13. Remove additional PPE, if used. Perform hand hygiene.
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Administering a Tube Feeding

Goal: The patient receives the tube feeding without complaints of nausea or episodes of vomiting.

1. Assemble equipment. Check amount, concentration, type, and frequency of tube feeding on patient’s chart. Check expiration date of formula.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed.

5. Assemble equipment on overbed table within reach.

6. Close the patient’s bedside curtain or door. Raise bed to a comfortable working position, usually elbow height of the caregiver (VISN 8, 2009). Perform key abdominal assessments as described above.

7. Position patient with head of bed elevated at least 30 to 45 degrees or as near normal position for eating as possible.

8. Put on gloves. Unpin tube from patient’s gown. Verify the position of the marking on the tube at the nostril. Measure length of exposed tube and compare with the documented length.

9. Attach syringe to end of tube and aspirate a small amount of stomach contents, as described in Skill 11-2.

10. Check the pH as described in Skill 11-2.

11. Visualize aspirated contents, checking for color and consistency.

12. If it is not possible to aspirate contents; assessments to check placement are inconclusive; the exposed tube length has changed; or there are any other indications that the tube is not in place, check placement by x-ray.

13. After multiple steps have been taken to ensure that the feeding tube is located in the stomach or small intestine, aspirate all gastric contents with the syringe and measure to check for the residual amount of feeding in the stomach. Return the residual based on facility policy. Proceed with feeding if amount of residual does not exceed agency policy or the limit indicated in the medical record.

14. Flush tube with 30 mL of water for irrigation. Disconnect syringe from tubing and cap end of tubing while preparing the formula feeding equipment. Remove gloves.

15. Put on gloves before preparing, assembling and handling any part of the feeding system.

16. Administer feeding.

When Using a Feeding Bag (Open System)
a. Label bag and/or tubing with date and time. Hang bag on IV pole and adjust to about 12 above the stomach. Clamp tubing.
b. Check the expiration date of the formula. Cleanse top of feeding container with a disinfectant before opening it. Pour formula into feeding bag and allow solution to run through tubing. Close clamp.
c. Attach feeding setup to feeding tube, open clamp, and regulate drip according to the medical order, or allow feeding to run in over 30 minutes.
d. Add 30 to 60 mL (1–2 oz) of water for irrigation to feeding bag when feeding is almost completed and allow it to run through the tube.
e. Clamp tubing immediately after water has been instilled. Disconnect feeding setup from feeding tube. Clamp tube and cover end with cap.

When Using a Large Syringe (Open System)
a. Remove plunger from 30- or 60-mL syringe.
b. Attach syringe to feeding tube, pour premeasured amount of tube feeding formula into syringe, open clamp, and allow food to enter tube. Regulate rate, fast or slow, by height of the syringe. Do not push formula with syringe plunger.
c. Add 30 to 60 mL (1–2 oz) of water for irrigation to syringe when feeding is almost completed, and allow it to run through the tube.
d. When syringe has emptied, hold syringe high and disconnect from tube. Clamp tube and cover end with cap.

When Using an Enteral Feeding Pump
a. Close flow-regulator clamp on tubing and fill feeding bag with prescribed formula. Amount used depends on agency policy. Place label on container with patient’s
name, date, and time the feeding was hung.
b. Hang feeding container on IV pole. Allow solution to flow through tubing.
c. Connect to feeding pump following manufacturer’s directions. Set rate. Maintain the patient in the upright position throughout the feeding. If the patient needs to
temporarily lie flat, the feeding should be paused. The feeding may be resumed after the patient’s position has been changed back to at least 30 to 45 degrees.
d. Check placement of tube and gastric residual every 4 to 6 hours.

17. Observe the patient’s response during and after tube feeding and assess the abdomen at least once a shift.

18. Have patient remain in upright position for at least 1 hour after feeding.

19. Remove equipment and return patient to a position of comfort. Remove gloves. Raise side rail and lower bed.

20. Put on gloves. Wash and clean equipment or replace according to agency policy. Remove gloves.

21. Remove additional PPE, if used. Perform hand hygiene.
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Inserting a Nasogastric (NG) Tube

Goal: The tube is passed into the patient's stomach without any complications.

1. Verify the medical order for insertion of an NG tube.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. Explain the procedure to the patient and provide the rationale as to why the tube is needed. Discuss the associated discomforts that may be experienced and possible
interventions that may allay this discomfort. Answer any questions as needed.

5. Gather equipment, including selection of the appropriate NG tube.

6. Close the patient’s bedside curtain or door. Raise bed to a comfortable working position; usually elbow height of the caregiver (VISN 8, 2009). Assist the patient to high Fowler’s position or elevate the head of the bed 45 degrees if the patient is unable to maintain upright position. Drape chest with bath towel or disposable pad. Have emesis basin and tissues handy.

7. Measure the distance to insert tube by placing tip of tube at patient’s nostril and extending to tip of earlobe and then to tip of xiphoid process. Mark tube with an indelible marker.

8. Put on gloves. Lubricate tip of tube (at least 2 –4 ) with water-soluble lubricant. Apply topical anesthetic to nostril and oropharynx, as appropriate.

9. After selecting the appropriate nostril, ask patient to slightly flex head back against the pillow. Gently insert the tube into the nostril while directing the tube upward and backward along the floor of the nose. Patient may gag when tube reaches pharynx. Provide tissues for tearing or watering of eyes. Offer comfort and reassurance to the patient.

10. When pharynx is reached, instruct patient to touch chin to chest. Encourage patient to sip water through a straw or swallow even if no fluids are permitted. Advance tube in downward and backward direction when patient swallows. Stop when patient breathes. If gagging and coughing persist, stop advancing the tube and check placement of tube with tongue blade and flashlight. If tube is curled, straighten the tube and attempt to advance again. Keep advancing tube until pen marking is reached. Do not use force. Rotate tube if it meets resistance.

11. Discontinue procedure and remove tube if there are signs of distress, such as gasping, coughing, cyanosis, and inability to speak or hum.

12. Secure the tube loosely to the nose or cheek until it is determined that the tube is in the patient’s stomach:
a. Attach syringe to end of tube and aspirate a small amount of stomach contents.
b. Measure the pH of aspirated fluid using pH paper or a meter. Place a drop of gastric secretions onto pH paper or place small amount in plastic cup and dip the pH
paper into it. Within 30 seconds, compare the color on the paper with the chart supplied by the manufacturer.
c. Visualize aspirated contents, checking for color and consistency.
d. Obtain radiograph (x-ray) of placement of tube, based on facility policy (and ordered by physician).

13. Apply skin barrier to tip and end of nose and allow to dry. Remove gloves and secure tube with a commercially prepared device (follow manufacturer’s directions) or tape to patient’s nose. To secure with tape:
a. Cut a 4 piece of tape and split bottom 2 or use packaged nose tape for NG tubes.
b. Place unsplit end over bridge of patient’s nose.
c. Wrap split ends under tubing and up and over onto nose. Be careful not to pull tube too tightly against nose.

14. Put on gloves. Clamp tube and remove the syringe. Cap the tube or attach tube to suction according to the medical orders.

15. Measure length of exposed tube. Reinforce marking on tube at nostril with indelible ink. Ask the patient to turn their head to the side opposite the nostril the tube is inserted. Secure tube to patient’s gown by using rubber band or tape and safety pin. For additional support, tube can be taped onto patient’s cheek using a piece of tape. If a double-lumen tube (e.g., Salem sump) is used, secure vent above stomach level. Attach at shoulder level.

16. Assist with or provide oral hygiene at 2- to 4-hour intervals. Lubricate the lips generously and clean nares and lubricate as needed. Offer analgesic throat lozenges or anesthetic spray for throat irritation if needed.

17. Remove equipment and return patient to a position of comfort. Remove gloves. Raise side rail and lower bed.

18. Remove additional PPE, if used. Perform hand hygiene.
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