12/22/13

Changing an IV Solution Container and Administration Set

Goal: The prescribed IV infusion continues without interruption and with infusion complications identified.

1. Verify IV solution order on MAR/CMAR with the medical order. Clarify any inconsistencies. Check the patient’s chart for allergies. Check for color, leaking, and expiration date. Know the purpose of the IV administration and medications if ordered.

2. Gather all equipment and bring to 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. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about allergies to medications or tape, as appropriate.

6. Compare IV container label with the MAR/CMAR. Remove IV bag from outer wrapper, if indicated. Check expiration dates. Scan bar code on container, if necessary. Compare patient identification band with the MAR/ CMAR. Alternately, label solution container with the patient’s name, solution type, additives, date, and time. Complete a time strip for the infusion and apply to IV container.

7. Maintain aseptic technique when opening sterile packages and IV solution. Remove administration set from package. Apply label to tubing reflecting the day/date for next set change, per facility guidelines.

To Change IV Solution Container
8. If using an electronic infusion device, pause the device or put on “hold.” Close the slide clamp on the administration set closest to the drip chamber. If using gravity infusion, close the roller clamp on the administration set.

9. Carefully remove the cap on the entry site of the new IV solution container and expose the entry site, taking care not to touch the exposed entry site.

10. Lift empty container off IV pole and invert it. Quickly remove the spike from the old IV container, being careful not to contaminate it. Discard old IV container.

11. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container. Alternately, follow the manufacturer’s directions for insertion. Hang the container on the IV pole.

12. Alternately, hang the new IV fluid container on an open hook on the IV pole. Carefully remove the cap on the entry site of the new IV solution container and expose the entry site, taking care not to touch the exposed entry site. Lift empty container off the IV pole and invert it. Quickly remove the spike from the old IV container, being careful not to contaminate it. Discard old IV container. Using a twisting and pushing motion, insert the administration set spike into the entry port of the new IV container as it hangs on the IV pole.

13. If using an electronic infusion device, open the slide clamp, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to “run” or “infuse.”

14. If using gravity infusion, slowly open the roller clamp on the administration set and count the drops. Adjust until the correct drop rate is achieved.

To Change IV Solution Container and Administration Set
15. Prepare the IV solution and administration set. Refer to Skill 15-1, Steps 7–11.

16. Hang the IV container on an open hook on the IV pole. Close the clamp on the existing IV administration set. Also, close the clamp on the short extension tubing connected to the IV catheter in the patient’s arm.

17. If using an electronic infusion device, remove the current administration set from device. Following manufacturer’s directions, insert a new administration set into infusion device.

18. Put on gloves. Remove the current infusion tubing from the access cap on the short extension IV tubing. Using an antimicrobial swab, cleanse access cap on extension tubing. Remove the end cap from the new administration set. Insert the end of the administration set into the access cap. Loop the administration set tubing near the entry site, and anchor with tape (nonallergenic) close to site.

19. Open the clamp on the extension tubing. Open the clamp on the administration set.

20. If using an electronic infusion device, open the slide clamp, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to “run” or “infuse.”

21. If using gravity infusion, slowly open the roller clamp on the administration set and count the drops. Adjust until the correct drop rate is achieved.

22. Remove equipment. Ensure patient’s comfort. Remove gloves. Lower bed, if not in lowest position.

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

24. Return to check flow rate and observe IV site for infiltration 30 minutes after starting infusion, and at least hourly thereafter. Ask the patient if he or she is experiencing any pain or discomfort related to the IV infusion.
Read More

Initiating a Peripheral Venous Access IV Infusion

Goal: The access device is inserted on the first attempt, using sterile technique.

1. Verify the IV solution order on the MAR/CMAR with the medical order. Clarify any inconsistencies. Check the patient’s chart for allergies. Check for color, leaking, and expiration date. Know techniques for IV insertion, precautions, purpose of the IV administration, and medications if ordered.

2. Gather all equipment and bring 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. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about allergies to medications, tape, or skin antiseptics, as appropriate. If considering using a local anesthetic, inquire about allergies for these substances as well.

6. If using a local anesthetic, explain the rationale and procedure to the patient. Apply the anesthetic to a few potential insertion sites. Allow sufficient time for the anesthetic to take effect.

Prepare the IV Solution and Administration Set

7. Compare the IV container label with the MAR/CMAR. Remove IV bag from outer wrapper, if indicated. Check expiration dates. Scan bar code on container, if necessary.
Compare on patient identification band with the MAR/CMAR. Alternately, label the solution container with the patient’s name, solution type, additives, date, and time.
Complete a time strip for the infusion and apply to IV container.

8. Maintain aseptic technique when opening sterile packages and IV solution. Remove administration set from package. Apply label to tubing reflecting the day/date for next set change, per facility guidelines.

9. Close the roller clamp or slide clamp on the IV administration set. Invert the IV solution container and remove the cap on the entry site, taking care not to touch the exposed entry site. Remove the cap from the spike on the administration set. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container. Alternately, follow the manufacturer’s directions for insertion.

10. Hang the IV container on the IV pole. Squeeze the drip chamber and fill at least halfway.

11. Open the IV tubing clamp, and allow fluid to move through tubing. Follow additional manufacturer’s instructions for specific electronic infusion pump, as indicated. Allow fluid to flow until all air bubbles have disappeared and the entire length of the tubing is primed (filled) with IV solution. Close the clamp. Alternately, some brands of tubing may require removal of the cap at the end of the IV tubing to allow fluid to flow. Maintain its sterility. After fluid has filled the tubing, recap the end of the tubing.

12. If an electronic device is to be used, follow manufacturer’s instructions for inserting tubing into the device.


Initiate Peripheral Venous Access
13. Place patient in low Fowler’s position in bed. Place protective towel or pad under patient’s arm.

14. Provide emotional support, as needed.

15. Open the short extension tubing package. Attach end cap, if not in place. Clean end cap with alcohol wipe. Insert syringe with normal saline into extension tubing. Fill extension tubing with normal saline and apply slide clamp. Remove the syringe and place extension tubing and syringe back on package, within easy reach.

16. Select and palpate for an appropriate vein. Refer to guidelines in previous Assessment section.

17. If the site is hairy and agency policy permits, clip a 2-inch area around the intended entry site.

18. Put on gloves.

19. Apply a tourniquet 3 to 4 inches above the venipuncture site to obstruct venous blood flow and distend the vein. Direct the ends of the tourniquet away from the entry site. Make sure the radial pulse is still present.

20. Instruct the patient to hold the arm lower than the heart.

21. Ask the patient to open and close the fist. Observe and palpate for a suitable vein. Try the following techniques if a vein cannot be felt:
a. Massage the patient’s arm from proximal to distal end and gently tap over intended vein.
b. Remove tourniquet and place warm, moist compresses over intended vein for 10 to 15 minutes.

22. Cleanse site with an antiseptic solution such as chlorhexidine or according to facility policy. Press applicator against the skin and apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow to dry completely.

23. Use the nondominant hand, placed about 1 or 2 inches below the entry site, to hold the skin taut against the vein. Avoid touching the prepared site. Ask the patient to remain still while performing the venipuncture.

24. Enter the skin gently, holding the catheter by the hub in your dominant hand, bevel side up, at a 10- to 15-degree angle. Insert the catheter from directly over the vein or from the side of the vein. While following the course of the vein, advance the needle or catheter into the vein. A sensation of “give” can be felt when the needle enters the vein.

25. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance either device into the vein until the hub is at the venipuncture site. The exact technique depends on the type of device used.

26. Release the tourniquet. Quickly remove the protective cap from the extension tubing and attach it to the catheter or needle. Stabilize the catheter or needle with your nondominant hand.

27. Continue to stabilize the catheter or needle and flush gently with the saline, observing the site for infiltration and leaking.

28. Open the skin protectant wipe. Apply the skin protectant to the site, making sure to apply at minimum the area to be covered with the dressing. Place sterile transparent dressing or catheter securing/stabilization device over venipuncture site. Loop the tubing near the site of entry, and anchor with tape (nonallergenic) close to the site.

29. Label the IV dressing with the date, time, site, and type and size of catheter or needle used for the infusion.

30. Using an antimicrobial swab, cleanse the access cap on the extension tubing. Remove the end cap from the administration set. Insert the end of the administration set into the end cap. Loop the administration set tubing near the site of entry, and anchor with tape (nonallergenic) close to the site. Remove gloves.

31. Open the clamp on the administration set. Set the flow rate and begin the fluid infusion. Alternately, start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the solution and function of the infusion device. Inspect the insertion site for signs of infiltration.

32. Apply an IV securement/stabilization device if not already in place as part of dressing, as indicated, based on facility policy. Explain to patient the purpose of the device and the importance of safeguarding the site when using the extremity.

33. Remove equipment and return the patient to a position of comfort. Lower bed, if not in lowest position.

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

35. Return to check flow rate and observe IV site for infiltration 30 minutes after starting infusion, and at least hourly thereafter. Ask the patient if he or she is experiencing any pain or discomfort related to the IV infusion.
Read More

Using a Handheld Resuscitation Bag and Mask

Goal: The patient exhibits signs and symptoms of adequate oxygen saturation.

1. If not a crisis situation, perform hand hygiene.

2. Put on PPE, as indicated.

3. If not an emergency, identify the patient.

4. 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.

5. Put on disposable gloves. Put on face shield or goggles and mask.

6. Ensure that the mask is connected to the bag device, the oxygen tubing is connected to the oxygen source, and the oxygen is turned on, at a flow rate of 10 to 15 L per minute. This may be done through visualization or by listening to the open end of the reservoir or tail: if air is heard flowing, the oxygen is attached and on.

7. If possible, get behind head of bed and remove headboard. Slightly hyperextend patient’s neck (unless contraindicated). If unable to hyperextend, use jaw thrust maneuver to open airway.

8. Place mask over patient’s face with opening over oral cavity. If mask is teardrop-shaped, the narrow portion should be placed over the bridge of the nose.

9. With dominant hand, place three fingers on the mandible, keeping head slightly hyperextended. Place thumb and one finger in C position around the mask, pressing hard enough to form a seal around the patient’s face.

10. Using nondominant hand, gently and slowly (over 2 to 3 seconds) squeeze the bag, watching chest for symmetric rise. If two people are available, one person should maintain a seal on the mask with two hands while the other squeezes the bag to deliver the ventilation and oxygenation.

11. Deliver the breaths with the patient’s own inspiratory effort, if present. Avoid delivering breaths when the patient exhales. Deliver one breath every 5 seconds, if patient’s own respiratory drive is absent. Continue delivering breaths until patient’s drive returns or until patient is intubated and attached to mechanical ventilation.

12. Dispose of equipment appropriately.

13. Remove face shield or goggles and mask. Remove gloves and additional PPE, if used. Perform hand hygiene.
Read More

Assisting With Removal of a Chest Tube

Goal: The chest tube is removed with minimal discomfort to the patient and the patient remains free of respiratory distress.

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. Administer pain medication, as prescribed. Premedicate patient before the chest tube removal, at a sufficient interval to allow for the medication to take effect, based on the medication prescribed.

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

6. Explain what you are going to do and the reason for doing it to the patient. Explain any nonpharmacologic pain interventions the patient may use to decrease discomfort during tube removal.

7. Put on clean gloves.

8. Provide reassurance to the patient while the physician removes the dressing and then the tube.

9. After physician has removed chest tube and secured the occlusive dressing, assess patient’s lung sounds, respiratory rate, oxygen saturation, and pain level.

10. Anticipate the physician ordering a chest x-ray.

11. Dispose of equipment appropriately.

12. Remove gloves and additional PPE, if used. Perform hand hygiene.
Read More

Providing Care of a Chest Drainage System

Goal: The patient does not experience any complications related to the chest drainage system or respiratory distress.

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.

6. Assess the patient’s level of pain. Administer prescribed medication, as needed.

7. Put on clean gloves.

Assessing the Drainage System
8. Move the patient’s gown to expose the chest tube insertion site. Keep the patient covered as much as possible, using a bath blanket to drape the patient, if necessary. Observe the dressing around the chest tube insertion site and ensure that it is dry, intact, and occlusive.

9. Check that all connections are securely taped. Gently palpate around the insertion site, feeling for subcutaneous emphysema, a collection of air or gas under the skin. This may feel crunchy or spongy, or like “popping” under your fingers.

10. Check drainage tubing to ensure that there are no dependent loops or kinks. Position the drainage collection device below the tube insertion site.

11. If the chest tube is ordered to be suctioned, note the fluid level in the suction chamber and check it with the amount of ordered suction. Look for bubbling in the suction chamber. Temporarily disconnect the suction to check the level of water in the chamber. Add sterile water or saline, if necessary, to maintain correct amount of suction.

12. Observe the water-seal chamber for fluctuations of the water level with the patient’s inspiration and expiration (tidaling). If suction is used, temporarily disconnect the suction to observe for fluctuation. Assess for the presence of bubbling in the water-seal chamber. Add water, if necessary, to maintain the level at the 2-cm mark, or the mark recommended by the manufacturer.

13. Assess the amount and type of fluid drainage. Measure drainage output at the end of each shift by marking the level on the container or placing a small piece of tape at the drainage level to indicate date and time. The amount should be a running total, because the drainage system is never emptied. If the drainage system fills, it is removed and replaced.

14. Remove gloves. Assist patient to a comfortable position. Raise the bed rail and place the bed in the lowest position, as necessary.

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

Changing the Drainage System
16. Obtain two padded Kelly clamps, a new drainage system, and a bottle of sterile water. Add water to the water-seal chamber in the new system until it reaches the 2-cm mark or the mark recommended by the manufacturer. Follow manufacturer’s directions to add water to suction system if suction is ordered.

17. Put on clean gloves and additional PPE, as indicated.

18. Apply Kelly clamps 1.5 to 2.5 inches from insertion site and 1 inch apart, going in opposite directions.

19. Remove the suction from the current drainage system. Unroll or use scissors to carefully cut away any foam tape on the connection of the chest tube and drainage system. Using a slight twisting motion, remove the drainage system. Do not pull on the chest tube.

20. Keeping the end of the chest tube sterile, insert the end of the new drainage system into the chest tube. Remove Kelly clamps. Reconnect suction, if ordered. Apply plastic bands or foam tape to chest tube/drainage system connection site.

21. Assess the patient and the drainage system as outlined (Steps 5–15).

22. Remove additional PPE, if used. Perform hand hygiene.
Read More

Providing Tracheostomy Care

Goal: The patient exhibits a tracheostomy tube and site free from drainage, secretions, and skin irritation or breakdown.

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 tracheostomy care. Assess patient’s pain and administer pain medication, if indicated.

6. Explain what you are going to do and the reason 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 position, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Lower side rail closest to you. If the 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 to waist height. Place a trash receptacle within easy reach of work area.

8. Put on face shield or goggles and mask. Suction tracheostomy, if necessary. If tracheostomy has just been suctioned, remove soiled site dressing and discard before
removal of gloves used to perform suctioning.

Cleaning the Tracheostomy: Disposable Inner Cannula
(See the Skill Variation in your skills book for steps for cleaning a nondisposable inner cannula.)

9. Carefully open the package with the new disposable inner cannula, taking care not to contaminate the cannula or the inside of the package. Carefully open the package with the sterile cotton-tipped applicators, taking care not to contaminate them. Open sterile cup or basin and fill 0.5 inch deep with saline. Open the plastic disposable bag and place within reach on work surface.

10. Put on disposable gloves.

11. Remove the oxygen source if one is present. Stabilize the outer cannula and faceplate of the tracheostomy with your nondominant hand. Grasp the locking mechanism of the inner cannula with your dominant hand. Press the tabs and release lock. Gently remove inner cannula and place in disposal bag. If not already removed, remove site dressing and dispose of it in the trash.

12. Discard gloves and put on sterile gloves. Pick up the new inner cannula with your dominant hand, stabilize the faceplate with your nondominant hand, and gently insert the new inner cannula into the outer cannula. Press the tabs to allow the lock to grab the outer cannula. Reapply oxygen source, if needed.

Applying Clean Dressing and Holder
(See the Skill Variations in your skills book for steps for an alternate site dressing if a commercially prepared sponge is not available and to secure a tracheostomy with a tracheostomy ties/tape instead of a collar.)

13. Remove oxygen source, if necessary. Dip cotton-tipped applicator or gauze sponge in cup or basin with sterile saline and clean stoma under faceplate. Use each applicator or sponge only once, moving from stoma site outward.

14. Pat skin gently with dry 4 4 gauze sponge.

15. Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 4-inch dressing under the faceplate.

16. Change the tracheostomy holder:
a. Obtain the assistance of a second individual to hold the tracheostomy tube in place while the old collar is removed and the new collar is placed.
b. Open the package for the new tracheostomy collar.
c. Both nurses should put on clean gloves.
d. One nurse holds the faceplate while the other pulls up the Velcro tabs. Gently remove the collar.
e. The first nurse continues to hold the tracheostomy faceplate.
f. The other nurse places the collar around the patient’s neck and inserts first one tab, then the other, into the openings on the faceplate and secures the Velcro tabs on the tracheostomy holder.
g. Check the fit of the tracheostomy collar. You should be able to fit one finger between the neck and the collar. Check to make sure that the patient can flex neck comfortably. Reapply oxygen source, if necessary.

17. Remove gloves. Assist patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.

18. Remove face shield or goggles and mask. Remove additional PPE, if used. Perform hand hygiene.

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

Suctioning the Tracheostomy: 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 to the patient what you are going to do and the reason or doing it, 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 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. 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. If using, place resuscitation bag connected to oxygen within convenient reach.

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. 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.

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

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

14. Using your nondominant hand and a manual resuscitation bag, hyperventilate the patient, delivering three to six breaths or use the sigh mechanism on a mechanical
ventilator.

15. Open the adapter on the mechanical ventilator tubing or remove oxygen delivery setup with your nondominant hand.

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

17. 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.

18. Hyperventilate the patient using your nondominant hand and a manual resuscitation bag, 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 and use the sigh mechanism on a mechanical ventilator.

19. 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.

20. 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. Encourage the patient to cough and deep breathe between suctionings. Suction the oropharynx after suctioning the trachea. Do not reinsert in the tracheostomy after suctioning the mouth.

21. 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.

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

23. Offer oral hygiene after suctioning.

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

25. Remove additional PPE, if used. Perform hand hygiene.
Read More

Securing an Endotracheal Tube

Goal: The tube remains in place, and the patient maintains bilaterally equal and clear lung sounds.

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. Assess the need for endotracheal tube retaping. Administer pain medication or sedation, as prescribed, before attempting to retape endotracheal tube. Explain the procedure to the patient.

6. Obtain the assistance of a second individual to hold the endotracheal tube in place while the old tape is removed and the new tape is placed.

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

8. Put on face shield or goggles and mask. Suction patient as described in Skill 14-8 or 14-9.

9. Measure a piece of tape for the length needed to reach around the patient’s neck to the mouth plus 8 inches. Cut tape. Lay it adhesive-side up on the table.

10. Cut another piece of tape long enough to reach from one jaw around the back of the neck to the other jaw. Lay this piece on the center of the longer piece on the table, matching the tapes’ adhesive sides together.

11. Take one 3-mL syringe or tongue blade and wrap the sticky tape around the syringe until the nonsticky area is reached. Do this for the other side as well.

12. Take one of the 3-mL syringes or tongue blades and pass it under the patient’s neck so that there is a 3-mL syringe on either side of the patient’s head.

13. Put on disposable gloves. Have the assistant put on gloves as well.

14. Provide oral care, including suctioning the oral cavity.

15. Take note of the ‘cm’ position markings on the tube. Begin to unwrap old tape from around the endotracheal tube. After one side is unwrapped, have assistant hold the endotracheal tube as close to the lips or nares as possible to offer stabilization.

16. Carefully remove the remaining tape from the endotracheal tube. After tape is removed, have assistant gently and slowly move endotracheal tube (if orally intubated) to the other side of the mouth. Assess mouth for any skin breakdown. Before applying new tape, make sure that markings on endotracheal tube are at same spot as when retaping began.

17. Remove old tape from cheeks and side of face. Use adhesive remover to remove excess adhesive from tape. Clean the face and neck with washcloth and cleanser. If patient has facial hair, consider shaving cheeks. Pat cheeks dry with the towel.

18. Apply the skin barrier to the patient’s face (under nose, cheeks, and lower lip) where the tape will sit. Unroll one side of the tape. Ensure that nonstick part of tape remains behind patient’s neck while pulling firmly on the tape. Place adhesive portion of tape snugly against patient’s cheek. Split the tape in half from the end to the corner of the mouth.

19. Place the top-half piece of tape under the patient’s nose. Wrap the lower half around the tube in one direction, such as over and around the tube. Fold over tab on end of tape.

20. Unwrap second side of tape. Split to corner of the mouth. Place the bottom-half piece of tape along the patient’s lower lip. Wrap the top half around the tube in the opposite direction, such as below and around the tube. Fold over tab on end of tape. Ensure tape is secure.

21. Auscultate lung sounds. Assess for cyanosis, oxygen saturation, chest symmetry, and stability of endotracheal tube. Again check to ensure that the tube is at the correct depth.

22. If the endotracheal tube is cuffed, check pressure of the balloon by attaching a handheld pressure gauge to the pilot balloon of the endotracheal tube.

23. Assist patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.

24. Remove face shield or goggles and mask. Remove additional PPE, if used. Perform hand hygiene.
Read More

Suctioning an Endotracheal Tube: Closed 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 to waist height.

8. 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.

9. Open the package of the closed suction device using aseptic technique. Make sure that the device remains sterile.

10. Put on sterile gloves.

11. Using nondominant hand, disconnect ventilator from endotracheal tube. Place ventilator tubing in a convenient location so that the inside of the tubing remains sterile or continue to hold the tubing in your nondominant hand.

12. Using dominant hand and keeping device sterile, connect the closed suctioning device so that the suctioning catheter is in line with the endotracheal tube.

13. Keeping the inside of the ventilator tubing sterile, attach ventilator tubing to port perpendicular to the endotracheal tube. Attach suction tubing to suction catheter.

14. Pop top off sterile normal saline dosette. Open plug to port by suction catheter and insert saline dosette or syringe.

15. Hyperventilate the patient by using the sigh button on the ventilator before suctioning. Turn safety cap on suction button of catheter so that button is depressed easily.

16. Grasp suction catheter through protective sheath, about 6 inches (15 cm) from the endotracheal tube. Gently insert the catheter into the endotracheal tube. Release the catheter while holding on to the protective sheath. Move hand farther back on catheter. Grasp catheter through sheath and repeat movement, advancing the catheter to the predetermined length. Do not occlude Y-port when inserting the catheter.

17. Apply intermittent suction by depressing the suction button with thumb of nondominant hand. Gently rotate the catheter with thumb and index finger of dominant hand as catheter is being withdrawn. Do not suction for more than 10 to 15 seconds at a time. Hyperoxygenate or hyperventilate with sigh button on ventilator, as ordered.

18. Once catheter is withdrawn back into sheath, depress the suction button while gently squeezing the normal saline dosette until the catheter is clean. 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.

19. When procedure is completed, ensure that the catheter is withdrawn into the sheath, and turn the safety button. Remove normal saline dosette and apply cap to port.

20. Suction the oral cavity with a separate single-use, disposable catheter and perform oral hygiene. Remove gloves. Turn off suction.

21. Assist patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.

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

23. Remove additional PPE, if used. Perform hand hygiene.
Read More
Subscribe to: Posts (Atom)