PRACTICAL SKILLS EXAM II.
List of Practical Skills that students must performed.
1. Surgical handwashing or scrub
2. Donning and removing clean and contaminated gowns and gloves
3. Applying sterile gloves via the open method
4. Applying sterile gloves and gown via the closed method
5. Turning and positioning a client
6. Moving a client in bed
7. Assisting from bed to stretcher
8. Assisting with ambulation and safe falling
9. Applying an elastic bandage
10. Bandaging
11. Cast care and comfort
12. Applying a dry dressing
13. Applying a transparent dressing
14. Applying a pressure bandage
15. Cleaning and dressing a wound with an open drain
16. Obtaining a wound drainage specimen for culturing
17. Preventing and managing the pressure ulcer
18. Applying moist heat
19. Applying dry heat
20. Applying cold treatment
21. Applying a condom catheter
22. Inserting an indwelling catheter: male
23. Inserting an indwelling catheter: female
24. Urine specimen from an indwelling catheter
25. Obtaining urine specimens
26. Assisting with a bedpan or urinal
27. Inserting and maintaining a nasogastric tube
28. Administering a large volume, cleansing enema
29. Administering a small volume, prepackaged enema
30. Administering a return-flow enema
31. Irrigating and cleaning a stoma
32. Changing a bowel diversion ostomy appliance: pouching a stoma
33. Assisting a client with controlled coughing and deep breathing
34. Postural drainage
35. Maintaining and cleaning endotracheal tubes
36. Maintaining and cleaning the tracheostomy tube
37. Emergency airway management
38. Performing the Heimlich Maneuver
39. Administering Cardiopulmonary Resuscitation (CPR)
PROCEDURE CHECKLISTS
Applying a Transparent Dressing
1. Places the patient in a comfortable position that provides easy access to the wound.
2. If a dressing is present, washes hands, applies clean gloves, and removes the old dressing.
3. Disposes of the soiled dressing and gloves in the biohazard waste.
4. Applies clean gloves and cleanses the skin surrounding the wound with normal saline or a mild cleansing agent. Rinses the skin well if a cleanser is used.
5. Allows the skin to dry.
6. If hair is present in the area where the dressing will be applied, clips the hair with scissors.
7. If the skin is oily, cleans the surrounding skin with alcohol or acetone and allows it to dry.
8. Cleanses the wound as ordered or according to agency procedure.
9. Correctly uses clean or sterile technique, depending on the nature of the wound.
10. Assesses the condition of the wound. Notes the size, location, type of tissue present, amount of exudate, and odor.
11. Removes the center backing liner from the transparent film dressing.
12. Holding the dressing by the edges, applies the transparent film to the wound. Maintains a slight stretch on the edges of the dressing when applying to prevent wrinkling.
13. Removes the edging liner from the dressing.
14. Properly disposes of soiled equipment and removes gloves.
Obtaining a Needle Aspiration Culture from a Wound
1. Administers pain medication 30 minutes prior to procedure, if necessary.
2. Positions the patient so the wound is easily accessible.
3. Positions a water-resistant disposable drape under the patient to collect fluid runoff.
4. After washing and drying hands, applies a gown, face shield, and clean gloves.
5. Removes the soiled dressing. Disposes of gloves and soiled dressing in a biohazard bag.
6. Sets up a sterile field using an impermeable barrier on the bedside table.
7. Opens packets of sterile 4×4 gauze onto the field. Moistens the gauze with 0.9% (normal) saline solution for irrigation.
8. As an alternative to setting up a sterile field (Steps 6 and 7), may use an impermeable tray of sterile 4×4 gauze. Removes the cover of the tray and moistens the gauze with sterile saline.
9. Attaches a 22 gauge needle to a 3 mL syringe and withdraws 1 mL of sterile 0.9% saline for injection from the vial.
10. Caps the needle, using a one-handed technique .
11. Applies sterile gloves.
12. Gently cleanses the wound with the saline moistened gauze by lightly wiping a section of the wound from the center toward the wound edge.
13. Discards the gauze in a biohazard receptacle and repeats in the next section using a new piece of gauze with each wiping pass.
14. Uncaps the syringe from the bedside table and inserts the needle 1 to
15. Injects 1 mL of 0.9% saline into the wound tissue.
16. Pulls back on the syringe plunger to aspirate approximately 1 mL of fluid into the barrel of the syringe. Removes the needle from the wound bed after collecting the aspirate.
17. Places the collected fluid into a culture tube containing culture medium.
18. Labels the culture tube with the patient’s name, birthdate, source of specimen, and date and time of collection. (A label may be supplied with the culture kit.)
19. Transports the culture to the lab.
20. Applies a clean dressing to the wound as ordered.
Obtaining a Wound Culture by Swab
1. Places the patient in a comfortable position that provides easy access to the wound and will allow the irrigation solution to flow freely from the wound, with the assistance of gravity.
2. Places a water-resistant disposable drape to protect the bedding from any runoff.
3. After washing and drying the hands, applies a gown, face shield, and clean gloves.
4. Removes the soiled dressing. Disposes of gloves and soiled dressing in a biohazard bag.
5. Applies clean gloves.
6. Places an emesis basin at the bottom of the wound to collect irrigation runoff.
7. Avoids touching the wound with the basin.
8. Attaches a 19 gauge Angiocath to a 35 cc syringe and fills it with normal saline irrigation solution.
9. Holding the Angiocath tip
10. Disposes of the syringe and Angiocath in the sharps container, and gloves in the biohazard waste.
11. Obtains a Culturette tube and twists the top of the tube to loosen the swab.
12. Applies clean gloves and locates an area of red, granulating tissue in the wound bed.
13. Withdraws the swab from the Culturette tube. Presses the swab against the granulating area and rotates the swab.
a. Does not allow the swab to touch anything other than the granulating area of the wound.
b. Does not swab culture areas with slough or eschar present.
14. Carefully inserts the swab back into the Culturette tube, making sure it does not make contact with the opening of tube upon reinsertion.
15. Twists the cap to secure the tube.
16. Crushes the ampule of culture medium at the bottom of the tube. (Note: Inspects the culture tube used to determine if this step is required.)
17. Labels the Culturette tube with the patient’s name, birthdate, source of specimen, and date and time of collection. (Labels may be provided with the Culturette kit.)
18. Applies a clean dressing to the wound as ordered.
Performing a Sterile Wound Irrigation
1. Administers pain medication 30 minutes prior to procedure, if necessary.
2. Warms irrigation solution.
3. Places the patient in a comfortable position that provides easy access to the wound and will allow the irrigation solution to flow freely from the wound, with the assistance of gravity.
4. Positions a water-resistant disposable drape to protect the bedding from any possible runoff.
5. After washing and drying hands, applies a gown, face shield, and clean gloves.
6. Removes the soiled dressing. Disposes of gloves and soiled dressing in a biohazard bag.
7. Sets up a sterile field on a clean dry surface.
8. Adds the following supplies to the field:
Sterile gauze
Sterile bowl
Dressing supplies
Variation A: A 19 gauge Angiocath, 35 cc syringe, and sterile emesis basin, or
Variation B: A sterile commercial irrigation kit
9. Pours the warmed irrigation solution into the sterile bowl.
10. Dons sterile gloves.
11. Irrigates the wound.
a. Places the sterile emesis basin at the bottom of the wound to collect irrigation runoff.
b. Variation A: Attaches the 19 gauge Angiocath to the 35 mL syringe and fills with the irrigation solution, or
Variation B: Fills a piston-tip or bulb syringe with irrigation solution.
c. Holding the Angiocath tip or syringe tip
d. Repeats the irrigation until the solution returns clear.
12. Removes the basin or sterile container from the base of the wound; pats the skin around the wound dry with sterile gauze, beginning at the top of the wound and working downward.
13. Dresses the wound as ordered.
14. Disposes of contaminated irrigation fluid in an appropriate manner (biohazardous waste).
15. Removes soiled drapes from the patient area.
16. Removes gloves, face shield, and gown; disposes of appropriately (they are biohazardous).
17. Washes hands.
18. Repositions patient to a comfortable position.
Removing and Applying Dry Dressings
Removing Old Dressing and Cleansing Wound
1. Places the patient in a comfortable position that provides easy access to the wound.
2. Washes hands and applies clean gloves.
3. Loosens the edges of the tape of the old dressing. Stabilizes the skin with one hand while pulling the tape in the opposite direction.
4. Beginning at the edges of the dressing, lifts the dressing toward the center of the wound.
5. If the dressing sticks, moistens it with 0.9% (normal) saline before completely removing it.
6. Assesses the type and amount of drainage present on the soiled dressing.
7. Disposes of soiled dressing and gloves in a biohazard bag.
8. Removes the cover of a tray of sterile 4×4 gauze. Moistens the gauze with sterile saline.
9. Applies clean gloves.
10. Gently cleanses the wound with the saline-moistened gauze by lightly wiping a section of the wound from the center toward the wound edge.
11. Discards the gauze in a biohazard receptacle and repeats in the next section, using a new piece of gauze with each wiping pass.
12. Discards gloves and soiled gauze into a biohazard bag.
Applying the Dry Dressing
1. Washes hands.
2. Opens sterile gauze packages on a clean, dry surface.
3. Applies clean gloves.
4. Applies a layer of dry dressings over the wound; if drainage is expected, uses an additional layer of dressings.
5. Removes gloves, turning them inside out, and discards in a biohazard receptacle.
6. Places strips of tape at the ends of the dressing and evenly spaced over the remainder of the dressing. Uses strips that are sufficiently long to secure the dressing in place.
Removing and Applying Wet-to-Damp Dressings
Removing the Soiled Dressing
1. Assesses for pain and medicates 30 minutes prior to procedure, if needed.
2. Places the patient in a comfortable position that provides easy access to the wound.
3. Washes hands and applies clean gloves.
4. Loosens the edges of the tape of the old dressing. Stabilizes the skin with the other hand while pulling the tape in the opposite direction.
5. Beginning with the top layer, lifts the dressing from the corner toward the center of the wound. If dressing sticks, moistens with 0.9% (normal) saline before completely removing it.
6. Continues to remove layers until the entire dressing is removed.
7. Assesses the type and amount of drainage present on the soiled dressing.
8. Disposes of soiled dressing and gloves in a biohazard bag.
9. Removes the cover of a tray of sterile 4×4 gauze; moistens the gauze with sterile saline.
10. Applies clean gloves.
11. Gently cleanses the wound with the saline-moistened gauze by lightly wiping a section of the wound from the center toward the wound edge.
12. Discards the gauze in a biohazard receptacle and repeats in the next section using a new piece of gauze with each wiping pass.
13. Discards gloves and soiled gauze into a biohazard bag.
14. Establishes a sterile field, using a sterile impermeable barrier.
15. Opens sterile gauze packs and a surgipad onto the sterile field. The amount of gauze used will depend on the size of the wound.
16. Moistens sterile gauze with a sterile 0.9% saline solution for irrigation.
17. Applies clean gloves.
18. Wrings out excess moisture from the gauze before applying.
19. Applies a single layer of moist fine-mesh gauze to the wound, being careful to place gauze in all depressions or crevices of the wound. Uses sterile forceps or cotton applicator to ensure that deep depressions or sinus tracts are filled with gauze.
20. Applies a secondary moist layer over the first layer. Repeats this process until the wound is completely filled with moistened sterile gauze.
21. Does not pack the gauze tightly into the wound.
22. Does not extend the moist dressing onto the surrounding skin.
23. Covers the moistened gauze with a surgipad.
24. Secures the dressing with tape or Montgomery straps.
25. Disposes of gloves and sterile field materials in the biohazard waste.
Assisting With Ambulation (One Nurse)
1. Puts non-skid slippers on the patient.
2. Applies a transfer belt.
3. Places bed in low position and locks the wheels.
4. Assists patient to dangle at the side of the bed (see checklist for Procedure Checklist Chapter 31: Dangling a Patient at the Side of the Bed).
5. Faces the patient. Braces feet and knees against the patient’s feet and knees, paying particular attention to any known weakness.
6. Bends the hips and knees and holds onto the transfer belt.
7. Instructs the patient to place her arms around the nurse between the shoulders and waist (the location depends on the nurse’s height and the height of the patient).
8. Asks the patient to stand as the nurse moves to an upright position by straightening the legs and hips.
9. Allows the patient to steady herself for a moment.
10. Stands at the patient’s side, placing both hands on the transfer belt.
11. If the patient has weakness on one side, positions self on the weaker side.
12. Slowly guides the patient forward, observing for signs of fatigue or dizziness.
13. If the patient must transport an IV pole, allows the patient to hold onto the pole on the side where the nurse is standing. Assists the patient to advance the pole as they ambulate.
PROCEDURE CHECKLIST
Moving a Patient Up In Bed
1. Acquires second person to help with moving patient.
2. Locks bed wheels.
3. Lowers head of bed; places patient supine.
4. Lowers side rail on “working” side; keeps side rail up on opposite side of the bed.
5. Ensures that a friction-reducing device such as a transfer roller sheet is in place; improvises with a plastic bag or film under patient, if needed.
6. Raises height of the bed to waist level.
7. Removes pillow from under patient’s head and places it at the head of the bed.
8. Instructs the patient to fold his arms across his chest. If an overhead trapeze is in place, asks the patient to hold the trapeze with both hands. Has the patient bend his knees with feet flat on the bed.
9. Instructs the patient to flex his neck.
10. Positions assistant on opposite side of bed; each grasps and rolls draw sheet close to patient.
11. Instructs the patient, on the count of three, to lift his trunk and push off with his heels toward the head of the bed.
12. Positions own feet with a wide base of support. Points the feet toward the direction of the move. Flexes own knees and hips.
13. Places own weight on the foot nearest to the foot of the bed. Counts to three and shifts weight forward.
14. Repeats until the patient is positioned near the head of the bed.
15. Straightens draw sheet, places a pillow under the patient’s head and assists him to a comfortable position.
16. Places the bed in low position, and raises the side rail.
17. Places the call light in a position where the patient can easily reach it
18. Performs Steps 1 through 10.
19. With a nurse positioned on either side of patient, uses the draw sheet to turn the patient to one side.
20. Positions a full body sling under the patient by placing the midline at the patient’s back and tucking it under the draw sheet.
21. Turns the patient to the opposite side and unrolls the full body sling..
22. Attaches the sling to the overbed lifting device or mechanical lift.
23. Engages the lift to raise the patient off of the bed. Advances the lift toward the head of the bed until the patient is at the desired level.
24. Lowers the lift and removes sling from underneath patient, if needed.
25. Turns patient to the desired position. Straightens the draw sheet and tucks it in tightly at the sides of the bed.
Assisting With Ambulation (Two Nurses)
1. Puts non-skid slippers on the patient.
2. Applies a transfer belt.
3. Places bed in low position.
4. Locks bed wheels.
5. Assists patient to dangle at the side of the bed.
6. Each nurse stands facing the patient on opposite sides of the patient, bracing their feet and knees against the patient’s, and paying particular attention to any known weakness.
7. Bends from the hips and knees, and holds onto the transfer belt.
8. Instructs the patient to place her arms around each of the nurses between the shoulders and waist (the location depends ourses’ height and the height of the patient).
9. Asks the patient to stand as the nurses move to an upright position by straightening their legs and hips.
10. Allows patient to steady herself for a moment.
11. Each nurse stands at the patient’s sides, grasping hold of the transfer belt.
12. Slowly guides the patient forward, observing for fatigue or dizziness.
13. If the patient must transport an IV pole, one nurse advances the IV pole along the side of the patient by holding the pole with the outside hand.
Transferring a Patient from Bed to Chair
1. Positions the chair next to the bed and near the head of the bed. If possible, locks the chair.
2. Puts non-skid slippers on the patient.
3. Applies the transfer belt.
4. Places bed in low position.
5. Locks the bed.
6. Assists patient to dangle at the side of the bed (see Procedure Checklist Chapter 31: Dangling a Patient at the Side of the Bed).
7. Faces the patient; braces feet and knees against the patient’s feet and knees. Pays particular attention to any known weakness.
8. Bends hips and knees; holds onto the transfer belt. If two nurses are available, one nurse should be on each side of the patient.
9. Instructs the patient to place her arms around the nurse between the shoulders and waist (the exact location depends on the height of the nurse and patient).
10. Asks patient to stand as the nurse moves to an upright position by straightening her legs and hips.
11. Allows the patient to steady herself for a moment.
12. Instructs the patient to pivot and turn with the nurse toward the chair.
13. Assists the patient to position herself in front of the chair and place her hands on the arms of the chair.
14. Has the patient flex her hips and knees as she lowers herself to the chair. Guides her motion while maintaining a firm hold of the patient.
15. Assists the patient to a comfortable position in the chair.
Dangling a Patient at the Side of the Bed
1. Locks bed wheels.
2. Places patient in supine position and raises the head of the bed to 90°.
3. Keeps side rail elevated on the side opposite where nurse is standing.
4. Places bed in low position.
5. Applies a gait transfer belt to the patient at waist level.
6. Stands facing the patient with a wide base of support. Places foot closest to the head of the bed forward of the other foot. Leans forward, bending at the hips with the knees flexed.
6. Positions hands on either side of the gait transfer belt.
7. Rocks onto the back foot while moving the patient into a sitting position on the side of the bed—by pulling the patient by the gait transfer belt.
8. Stays with the patient as he dangles.
Transferring a Patient from Bed to Stretcher
1. Locks the bed.
2. Positions the bed flat (if the patient can tolerate being supine) and at the height of the stretcher.
3. Lowers the side rails.
4. Positions at least one nurse on each side of the bed.
5. Moves the patient to the side of the bed where the stretcher will be placed by rolling up the draw sheet close to the patient’s body and pulling.
6. Aligns the patient’s legs and head with her trunk.
7. Positions stretcher next to the bed.
8. Locks stretcher.
9. Nurse on the side of the bed opposite the stretcher uses draw sheet to turn the client away from the stretcher; the other nurse places the transfer board with a friction-reducing device such as a transfer roller sheet against the patient’s back, halfway between the bed and the stretcher.
10. Uses draw sheet to slide the patient across the transfer board onto the stretcher.
11. Turns the patient away from the bed and removes the board and transfer roller sheet.
12. Repositions patient on the stretcher for comfort and alignment; provides a blanket if needed.
13. Fastens safety belts and raises stretcher side rails.
14. Follows steps 1 through 4 above.
15. Nurse on the side of the bed opposite the stretcher uses draw sheet to turn the client away from the stretcher; the other nurse positions the midline of the slip sheet under the patient. Rolls the remaining half tightly and tucks under patient.
16. Turns the patient to the opposite side and pulls the slip sheet from under the patient.
17. Lowers the side rail on the side where the stretcher will be placed.
18. Positions the stretcher next to the bed and locks the wheels.
19. Positions at least two nurses on the far side of the stretcher. Pulls the patient onto the stretcher by pulling on the slip sheet.
20. Follows steps 11 through 13 above.
Turning a Patient in Bed
1. Acquires second person to help with turning.
2. Locks the bed.
3. Lowers the head of the bed and places patient supine.
4. Positions self and assistant on opposite sides of the bed.
5. Lowers the side rails.
6. Ensures that a friction-reducing device such as a transfer roller sheet is in place; improvises with a plastic bag or film under patient, if needed.
7. Raises height of the bed to waist level.
8. Moves the patient to the side of the bed he is turning him away from by rolling up the draw sheet close to the patient’s body and pulling.
9. Aligns the patient’s legs and head with his trunk.
10. Places the patient’s near leg and foot across the far leg (e.g., when turning right, places left leg over right).
11. Places the patient’s near arm across his chest. Abducts and externally rotates the other arm and shoulder.
12. Stands with a wide base of support with one foot forward of the other.
13. Grasps draw sheet at level of shoulders and hips. .
14. Places weight on the forward foot.
15. Bends from the hips and knees.
16. Instructs the patient that the turn will occur on the count of three.
17. If positioned on the side toward which the patient will turn, flexes own knees and hips and shifts weight to the back foot while pulling on the draw sheet at the hip and shoulder level, If positioned on the opposite side, shifts weight forward.
18. Positions patient’s dependent shoulder forward.
19. Places pillows to maintain patient in lateral position.
20. Places the bed in low position and raises the side rails.
21. Places the call light in easy reach.
ADMINISTERING A CLEANSING ENEMA
1. Determines patient’s ability to retain the enema solution.
2. Places a bedpan or bedside commode nearby for the patient with limited mobility.
3. Warms the solution to 105°–110°F —not in a microwave. Checks temperature with bath thermometer.
4. Opens the enema kit or obtains supplies.
5. Attaches tubing to the enema bucket if a bucket is being used (the 1-liter enema bag comes with preconnected tubing).
6. Closes the clamp on the tubing and fills the container with 500–1100 mL of warm solution (40–150 mL for infants; 250–350 mL for toddlers; 300–500 mL for school-age children).
7. Checks water with a bath thermometer. Temperature should be 105–110 degrees F (lukewarm).
8. Adds Castile soap or soap solution used by the facility, if a soapsuds enema was ordered.
9. Hangs the container on the IV pole.
10. Holding the end of the tubing over a sink or waste can, opens the clamp and slowly allows the tubing to prime (fill) with solution. Reclamps when filled.
11. Has the patient turn or assists to turn to a left side-lying position with the right knee flexed. (Elevates head of the bed very slightly for patients who have shortness of breath.)
12. Drapes patient with bath blanket, leaving only the buttocks and rectum exposed.
13. Dons clean procedure gloves.
14. Places a waterproof pad under the patient’s buttocks/hips.
15. Places the bedpan flat on the bed directly beneath the rectum, up against the patient’s buttocks; or places the bedside commode near the bed.
16. Generously lubricates the tip of the enema tubing.
17. If necessary, lifts the superior buttock to expose the anus.
18. Slowly and gently inserts tip of the tubing approximately 3 to
19. If tube does not pass with ease, does not force; allows a small amount of fluid to infuse and then tries again.
20. Removes the container from the IV pole and holds it at the level of the patient’s hips. Begins instilling the solution.
21. Slowly raises the level of the container so that it is 12 to
22. Continues a slow, steady instillation of the enema solution.
23. Continuously monitors the patient for pain or discomfort. If pain occurs or resistance is met at any time during procedure, stops and consults with primary care provider.
24. Assesses ability to retain the solution. If the patient has difficulty with retention, lowers the level of the container, stops the flow for 15–30 seconds, and then resumes the procedure.
25. When the correct amount of solution has been instilled, clamps the tubing and slowly removes the tubing from the rectum.
26. If there is stool on the tubing, wraps the end of the tubing in a washcloth or toilet tissue until it can be rinsed or disposed of.
27. Cleanses the patient’s rectal area.
28. Re-covers the patient.
29. Instructs patient to hold the enema solution for 5 to 10 minutes.
30. Places call light within reach.
31. Disposes of enema supplies or, if reusable, cleans and stores in an appropriate location in the patient’s room.
32. Removes gloves; washes hands.
33. Depending on the patient’s mobility status, assists onto the bedpan, to the bedside commode, or to the toilet when she feels compelled to defecate.
34. After the patient has defecated, inspects the stool for color, consistency, and quantity.
Placing and Removing a Bedpan
1. Determines whether patient needs regular bedpan or fracture pan.
2. Obtains the necessary supplies and proceeds to the patient’s room. Leaves clean washcloths, towel, and basin with warm water at the bedside for use during bedpan removal.
3. If the bedpan is metal, places it under warm, running water for a few seconds; then dries, making sure bedpan is not too hot.
4. Raises side rail on the opposite side of the bed, if not already up.
5. Raises the bed to a comfortable working height.
6. Prepares the patient by folding down the covers to a point that will allow placement of the bedpan.
7. Dons clean procedure gloves.
8. Notes the presence of dressings, drains, intravenous fluids, and traction.
9. Places patient supine; lowers the head of the bed.
10a. Asks the patient to lift his hips. The patient may need to raise his knees to a flexed position, place his feet flat on the bed and push up. Slides a hand under the small of the patient’s back, as needed, to assist the patient.
10b. Alternatively, places patient in a semi-Fowler’s position; asks him to raise his hips by pushing up on raised side rails or by using an over-bed trapeze.
11. Places the bedpan under the patient’s buttocks with the wide, rounded end toward the back. When using a fracture pan, places the wide, rounded end toward the front.
12. Does not “push” the pan under the patient’s buttocks.
13. Repositions the patient:
a. Replaces the covers; raises the head of the bed to a position of comfort for the patient.
b. Places a rolled towel, blanket, or small pillow under the sacrum (lumbar curve of the back).
c. Places the call light and toilet tissue within the patient’s reach.
d. Places bed back in its lowest position and raises both upper side rails.
14. Removes gloves and washes hands.
15. Asks for help from another healthcare worker, as needed.
16. With patient supine, lowers the head of the bed.
17. Assists patient to a side-lying position, using a turning sheet if necessary.
18. Places the bedpan up against the patient’s buttocks with the wide, rounded end toward the head. When using a fracture pan, places the wide rounded end toward the feet.
19. Holding the bedpan in place, slowly rolls the patient back and onto the bedpan.
20. Repositions the patient:
a. Replaces the covers; raises the head of the bed to a position of comfort for the patient.
b. Places a rolled towel, blanket, or small pillow under the sacrum (lumbar curve of the back).
c. Places the call light and toilet tissue within the patient’s reach.
d. Places bed back in its lowest position and raises both upper side rails.
21. Removes gloves and washes hands.
22. Dons clean procedure gloves.
23. Wets the washcloth(s) with warm water and places near the work area.
24. Lowers head of bed; raises bed to comfortable working height.
25. Pulls covers down only as far as necessary to remove the bedpan.
26. Offers the patient toilet paper (assists as needed).
27. Asks the patient to raise her hips. Stabilizes and removes the bedpan. If the patient is unable to raise her hips, stabilizes the bedpan and assists her to the side-lying position.
28. Cleanses the buttocks with a warm, wet washcloth; dries with a towel.
29. Replaces covers and positions patient for comfort.
30. Offers the second warm, moistened washcloth to the patient to cleanse her hands.
31. Empties the bedpan in the patient’s toilet.
32. Measures output if I&O is part of the treatment plan.
33. Cleans bedpan following facility guidelines.
34. Removes soiled gloves and washes hands.
Administering a Prepackaged Enema
1. Determines patient’s ability to retain the enema solution.
2. Places a bedpan or bedside commode nearby for the patient with limited mobility.
3. Warms the solution—not in a microwave.
4. Has the patient turn or assists to turn to a left side-lying position with the right knee flexed. (Elevates head of the bed very slightly for patients who have shortness of breath.)
5. Drapes patient with bath blanket, leaving only the buttocks and rectum exposed.
6. Dons clean procedure gloves.
7. Places a waterproof pad under the patient’s buttocks/hips.
8. Opens the prepackaged enema. Removes the plastic cap from the container. The tip of the prepackaged enema container comes prelubricated. Adds extra lubricant as needed.
9. If necessary, lifts the superior buttock to expose the anus.
10. Slowly and gently inserts tip of the tubing approximately 3 to
11. If tube does not insert with ease, does not force; removes, relubricates, and retries.
12. Tilts container slightly and slowly rolls and squeezes the container until all of the solution is instilled.
13. Withdraws container tip from the rectum; wipes the area with a washcloth or toilet tissue.
14. Cleans the patient’s rectal area, re-covers the patient and instructs to hold the enema solution for approximately 5–10 minutes.
15. Removes gloves; washes hands.
16. Places call light within reach.
17. Disposes of empty container.
18. Depending on the patient’s mobility status, assists onto the bedpan, to the bedside commode, or to the toilet when she feels compelled to defecate.
Removing Stool Digitally
1. Trims and files own fingernails if they extend over the end of the fingertips.
2. Obtains baseline vital signs and determines whether the patient has a history of cardiac problems or other contraindications.
3. Checks to see if an oil retention enema is ordered prior to and/or after the procedure. Administers, if so.
4. Obtains correct lubricant (e.g., Lidocaine, if ordered).
5. Assists patient to turn to his left side with his right knee flexed toward his head.
6. Places a waterproof pad halfway beneath the left hip.
7. Drapes patient to expose only the rectal area.
8. Dons clean procedure gloves; double gloves if desired or if dictated by policy.
9. Exposes patient’s buttocks; places a clean, dry bedpan on the waterproof pad, next to the buttocks.
10. Wets a washcloth or places toilet tissue or moist towelette nearby to cleanse rectal area upon completion of the procedure.
11. Generously lubricates the gloved forefinger and/or middle finger of the dominant hand.
12. Slowly slides one lubricated finger into the rectum. Observes for perianal irritation.
13. Gently rotates the finger around the mass and/or into the mass.
14. Begins to break the stool into smaller pieces. One method is to insert a second finger and gently “slice” apart the stool using a scissoring motion. Removes pieces of stool as they become separated, and places them in the bedpan.
15. Instructs the patient to take slow, deep breaths during the procedure.
16. Allowing patient to rest at intervals, continues to manipulate and remove pieces of stool.
17. Reapplies lubricant each time fingers are reinserted.
18. Assesses the patient’s heart rate at regular intervals. Stops the procedure if heart rate falls or rhythm changes from the initial assessment.
19. Depending on agency policy and nursing judgment, limits session to four finger insertions and gives a suppository between subsequent sessions.
20. When removal of stool is complete, covers bedpan and sets aside.
21. Uses washcloth and/or toilet tissue to cleanse the rectal area.
22. Assists patient to a position of comfort.
23. Notes color, amount, and consistency of stool.
24. Disposes of stool and cleans bedpan properly.
25. Removes gloves and washes hands.
Changing an Ostomy Appliance
1. Washes hands and dons clean procedure gloves.
2. Folds down the linens to expose the ostomy site; places a clean towel across the patient’s abdomen under the existing pouch.
3. Positions the patient so that no skin folds occur along the line of the stoma.
4. If the pouch is drainable, opens it by removing the clamp and unrolling it at the bottom.
5. Empties the existing ostomy pouch into a bedpan.
6. Saves the clamp for re-use (note that some pouches cannot be drained).
7. With one hand, gently removes the old wafer from the skin, beginning at the top and proceeding in a downward direction. At the same time, uses the other hand to hold tension on the skin in the opposite direction of the pull.
8. If resistance is encountered and the wafer is difficult to remove, uses adhesive remover or rubbing alcohol, according to facility protocol.
9. Places the old pouch and wafer in a plastic bag for disposal. If the pouch is nondrainable, disposes of it according to agency protocol.
10. Inspects stoma and peristomal skin.
11. Uses warm water and mild soap to cleanse stoma and surrounding skin.
12. Reports excess bleeding to the physician.
13. Allows the area to dry.
14. Measures the size of the stoma in one of the following ways:
a. Using a standard stoma measuring guide placed over the stoma.
b. Re-using a previously cut template.
c. Measuring the stoma from side to side (approximating the circumference).
15. Places a clean 4×4 gauze pad over the stoma.
16. Removes gloves and washes hands.
17. Traces the size of the opening obtained in Step 14 onto the paper on the back of the new wafer; cuts the opening. Wafer opening is approximately 1/16 to 1/8 inch (1.5–3 cm) larger than the circumference of the stoma.
18. Peels the paper off the wafer. Some resources suggest first holding the wafer between the palms of the hands to warm the adhesive ring.
19. NOTE: Some ostomy wafers come with an outer ring of tape attached. If so, does not remove the backing on this tape until the wafer is securely positioned (Steps 22–24).
20. Dons clean procedure gloves.
21. If ostomy skin care products are to be used, applies them at this time (e.g., wipes around stoma with skin-prep, applies skin barrier powder or paste, applies extra adhesive paste).
22. Removes the gauze. Centers the wafer opening around the stoma and gently presses down.
a. If using a one-piece pouch, makes sure the bag is pointed toward the patient’s feet.
b. If using a two-piece system, places the wafer on first. When the seal is complete, attaches the bag following manufacturer’s instructions.
c. For an open-ended pouch, folds the end of the pouch over the clamp and closes the clamp, listening for a “click” to ensure it is secure.
23. Asks the patient to place her hand over the newly applied wafer to warm the adhesive ring, making it adhere better. Some sources also suggest taping down the edges of the wafer.
24. Removes gloves and washes hands.
25. Returns patient to a comfortable position.
26. Disposes of used ostomy pouch following agency policy for biohazardous waste.
Testing Stool for Occult Blood
1. Determines whether the test will be done by the nurse at the point of service or by lab personnel.
2. Has the patient void before collecting the stool specimen.
3. Dons procedure gloves.
4. Places a clean, dry container for the stool specimen into the toilet or bedside commode in such a manner that the urine falls into the toilet and the fecal specimen falls into the container. Obtains a clean, dry bedpan for the patient who is immobile.
5. Instructs the patient to defecate into the container, or places the patient on the bedpan.
6. Does not contaminate the specimen with toilet tissue.
7. Explains the purpose of the test and that serial specimens may be needed.
8. Washes hands; removes gloves.
9. Once the specimen has been obtained, gathers the necessary testing supplies.
10. Reads the directions for the testing kit.
11. Dons clean procedure gloves.
12. Opens the specimen side of the Hemoccult (or other) slide. With a wooden tongue blade or other applicator, collects a small sample of stool and spreads thinly onto one “window” of the slide.
13. Uses a different applicator or the opposite end of the tongue blade to collect a second small sample of stool.
14. Spreads the second sample thinly onto the second “window” of the slide.
15. Wraps tongue blade in tissue and paper towel; places in waste receptacle. Does not flush it.
16. Closes the Hemoccult slide.
17. If the test is to be done by laboratory personnel, labels the specimen properly and places into the proper receptacle for transportation to the lab.
18. If test is to be done at the bedside, turns the slide over and opens the opposite side of the package.
19. Places one or two drops of developing solution onto each window (follows package directions).
20. Follows package directions for interpreting test results.
Irrigating a Colostomy
1. Places IV pole near where the procedure will take place (e.g., in the bathroom, next to the bedside commode, or next to the bed).
2. Assists the patient to the bathroom (if possible).
3. Asks the patient if she prefers to sit directly on the toilet or on a chair in front of it.
4. Prepares the irrigation container.
a. For two-piece systems, connects the tubing to the container.
b. Clamps the tubing. Fills the container with
500–1000 mL of warm tap water.
5. Primes the tubing; unclamps the tubing to allow for filling.
6. Hangs the solution container on the IV pole. Adjusts the IV pole to be at the height of the patient’s shoulder (approximately
7. Washes hands and dons clean procedure gloves.
8. Removes the existing colostomy appliance (if patient is wearing one) following the steps in Procedure Checklist Chapter 28: Changing an Ostomy Appliance.
9. Inspects the stoma and surrounding skin area.
10. Disposes of the used colostomy appliance properly. Empties contents into bedpan or toilet and discards the pouch in a moisture-proof (e.g., plastic) bag.
11. Applies the colostomy irrigation sleeve, following manufacturer’s directions.
a. Sleeves with adhesive backing are applied following pouch application steps found in Procedure Checklist Chapter 28: Changing an Ostomy Appliance.
b. For sleeves without an adhesive backing, places the belt around the patient’s waist and attaches ends to the pouch flange on either side.
c. For patients sitting in front of the toilet or bedside commode, places a waterproof pad under the sleeve over the patient’s thighs.
12. Note: For patients sitting directly on a toilet or bedside commode, the end of the sleeve should hang down past the patient’s pubic area, but not down into the water. For a patient in bed, the end of the sleeve should go into the bedpan.
13. Generously lubricates the cone at the end of the irrigation tubing with water-soluble lubricant.
14. Opens the top of the irrigation sleeve; inserts the cone gently into the colostomy stoma and holds it solidly in place.
15. Opens the clamp on the tubing and slowly begins the flow of water. The fluid should flow in at a rate of about
16. If the patient complains of discomfort, stops the flow for 15–30 seconds and has the patient take deep breaths.
17. When the correct amount of solution has instilled, clamps the tubing and removes the cone from the stoma.
18. Wraps the end of the cone in tissue or paper towel until it can be cleaned or disposed of properly.
19. Closes the top of the irrigation sleeve with a clamp.
20. Has the patient remain sitting until most of the irrigation fluid and bowel contents have evacuated.
Note: Can also clamp the end of the sleeve and have the patient ambulate to stimulate compete evacuation of stool.
21. When evacuation is complete, opens the top clamp, rinses and removes the irrigation sleeve. Sets it aside.
22. Cleanses the stoma and peristomal area with a warm washcloth; allows to dry.
23. Applies a new colostomy appliance, if patient is wearing one, following the steps in Procedure Checklist Changing an Ostomy Appliance. Otherwise, covers the stoma with a small gauze bandage.
24. Cleans the irrigation sleeve with mild soap and water. Allows it to dry.
25. Places the irrigation supplies in the proper place (e.g., in a plastic container or plastic bag).
26. Removes gloves and washes hands.
27. Assists the patient back to a position of comfort.
Administering a Blood Transfusion
1. Verifies that informed consent has been obtained.
2. Verifies the physician’s order, noting the indication, rate of infusion, and any premedication orders.
3. Administers any pretransfusion medications as prescribed.
4. Obtains IV fluid containing normal saline solution and a blood administration set.
5. Obtains the blood product from the blood bank according to agency policy.
6. Wears procedure gloves whenever handling blood products.
7. Rechecks the physician’s order.
8. With another qualified staff member (as deemed by the institution) verifies the patient and blood product identification, as follows:
a. Has the patient state his full name and date of birth (if he is able) and compares it to the name and date of birth located on the blood bank form.
b. Compares the patient name and hospital identificatioumber on the patient’s identification bracelet with the patient name and hospital identification number on the blood bank form attached to the blood product.
c. Compares the unit identificatioumber located on the blood bank form with the identificatioumber printed on the blood product container.
d. Compares the patient’s blood type listed on the blood bank form with the blood type listed on the blood product container.
e. If all verifications are in agreement, both staff members sign the blood bank form attached to the blood product container. Contacts the blood bank immediately if any discrepancies occur during the identification process; and does not administer the blood product.
f. Documents on the blood bank form the date and time that the transfusion was begun.
g. Makes sure that the blood bank form remains attached to the blood product container until administration is complete.
9. Removes the blood administration set from the package and labels the tubing with the date and time.
10. Closes the clamps on the administration set.
11. Removes the protective covers from the normal saline solution container port and one of the spikes located on the “Y” of the blood product administration set. Places the spike into the port of the solution container and opens the roller clamp closest to that spike.
12. Hangs the normal saline solution container on the IV pole.
13. Compresses the drip chamber of the administration set and allows it to fill up half way.
14. Primes the administration set with normal saline.
15. Attaches the blood filter to the second “Y” port on the administration set and primes it with normal saline solution by inverting it.
16. Inspects the tubing for air. If air bubbles remain in the tubing, flicks the tubing with a fingernail to mobilize the bubbles.
17. Gently inverts the blood product container several times.
18. Removes the protective covers from the administration set and the blood product port. Carefully spikes the blood product container through the port.
19. Hangs the blood product container on the IV pole.
20. Slowly opens the roller clamp closest to the blood product.
21. Obtains and records the patient’s vital signs, including temperature, before beginning the transfusion.
22. Using aseptic technique, attaches the distal end of the administration set to the IV catheter.
23. Using the roller clamp, adjusts the drip rate, as prescribed. (Keep in mind that blood administration sets have a drip factor of 10 drops/mL.).
24. Remains with the patient during the first 5 minutes and then obtains vital signs.
25. Makes sure that the patient’s call bell or light is readily available and tells him alert the nurse immediately of any signs or symptoms of a transfusion reaction, such as back pain, chills, itching, or shortness of breath.
26. Obtains vital signs in 15 minutes, then again in 30 minutes, and then hourly while the transfusion infuses.
27. After the unit has infused, closes the roller clamp closest to the blood product container and opens the roller clamp closest to the normal saline solution to flush the administration set with normal saline solution.
28. Closes the roller clamp and then disconnects the blood administration set from the IV catheter.
29. If another unit of blood is required, the second unit can be hung with the same administration set.
30. Discards the empty blood container and administration set in the proper receptacle according to agency policy.
31. Stops the transfusion immediately if signs or symptoms of a transfusion reaction occur.
32. Does not flush the tubing with the normal saline solution attached to the blood administration set.
33. Disconnects the administration set from the IV catheter.
34. Obtains vital signs and auscultates heart and breath sounds.
35. Maintains a patent IV catheter by hanging a new infusion of normal saline solution, using new tubing.
36. Notifies physician as soon as the blood has been stopped and patient has been assessed.
37. Places the administration set and blood product container with the blood bank form attached inside a biohazard bag and sends it to the blood bank immediately.
38. Obtains blood (in the extremity opposite the transfusion site) and urine specimens according to agency policy.
39. Continues to monitor vital signs frequently.
40. Administers medications as prescribed.
Regulating the IV Flow Rate
1. Uses the six rights of medication administration. Checks the solution to make sure that the proper IV fluid is hanging with the prescribed additives. Also verifies the infusion rate.
2. Calculates the hourly rate if it is not specified in the order. (Divides the volume to be infused by the number of hours it is to be infused. For example if the physician prescribes 1,000 mL to run over 4 hours, the infusion rate is 250 mL/hour).
3. Calculates the drip rate by multiplying the number of mL to be infused in 60 minutes by the drop factor in drops/mL; then divides by 60 minutes:
Hourly rate in mL × drop factor = drip rate
60 minutes
4. Verifies calculations.
5. Applies a time tape to the IV solution container next to the volume markings. Marks the time tape with the time that the infusion was started. Continues to mark 1-hour intervals on the time tape until reaching the bottom of the container.
6. Opens the roller clamp so that the IV fluid begins to flow.
7. Using a watch, counts the number of drops entering the drip chamber in 1 minute.
8. Adjusts the roller clamp by increasing or decreasing the flow until the prescribed drip rate is achieved.
9. Monitors the infusion rate 15 minutes after the infusion is begun; then monitors hourly.
Administering Oxygen by Cannula, Face Mask, or Face Tent
1. Attaches the flow meter to the wall oxygen source. If using a portable oxygen tank, attaches the flow meter to the tank if it is not already connected.
2. Assembles and applies the oxygen equipment.
Variation: Nasal Cannula
3. Attaches the humidifier to the flow meter. (Humidification is only necessary for flow rates of > 3 LPM.) If a humidifier is not used, attaches the adapter to the flow meter.
4. Attaches the nasal cannula to the humidifier or the adapter.
5. Places the nasal prongs in the patient’s nares, then places the tubing around each ear.
6. Uses the slide adjustment device to tighten the cannula under the patient’s chin.
7. Turns on the oxygen, using the flow meter, and adjusts it according to the prescribed flow rate.
8. Makes sure that the oxygen equipment is set up correctly and functioning properly before leaving the patient’s bedside.
Variation: Face Mask
9. Attaches the prefilled humidifier to the flow meter.
10. Attaches the oxygen tubing from the mask to the humidifier.
11. Gently places the face mask on the patient’s face, applying it from the bridge of the nose to under the chin.
12. Secures the elastic band around the back of the patient’s head, making sure the mask fits snugly but comfortably.
13. Turns on the oxygen, using the flow meter, and adjusts it according to the prescribed flow rate.
14. Makes sure that the oxygen equipment is set up correctly and functioning properly before leaving the patient’s bedside.
15. Attaches the prefilled humidifier to the flow meter.
16. Attaches the oxygen tubing to the face tent.
17. Attaches the oxygen tubing to the humidifier.
18. Gently places the face tent in front of the patient’s face, making sure that it fits under the chin.
19. Secures the elastic band around the back of the patient’s head.
20. Turns on the oxygen using the flow meter and adjusts it according to the prescribed flow rate.
21. Makes sure that the oxygen equipment is set up correctly and functioning properly before leaving the patient’s bedside.
Performing Tracheostomy Care
1. Places the patient in semi-Fowler’s position.
2. Places a towel or linen-saver pad over the patient’s chest.
3. Dons sterile gloves (alternatively, puts a sterile glove on the dominant hand and a clean glove on the other hand).
4. Suctions the tracheostomy (see Procedure Checklist Chapter 35: Performing Tracheostomy or Endotracheal Suctioning).
5. Removes and discards the soiled tracheostomy dressing in a biohazard receptacle; then removes and discards gloves.
6. Place the tracheostomy care equipment on the over-the-bed table and prepares the equipment using sterile technique:
a. Pours hydrogen peroxide into one of the sterile solution containers and pours normal saline solution into the other one.
b. Opens three 4×4 gauze packages; wets the gauze in one package with hydrogen peroxide; wets the gauze in another package with normal saline; keeps the third package dry.
c. Opens 2 cotton-tipped applicator packages. Wets the applicators in one package with normal saline solution and wets the applicators in the other package with hydrogen peroxide.
d. Opens the package containing a new disposable inner cannula, if available.
e. Opens the package of Velcro tracheostomy ties or cuts a length of twill tape long enough to go around the patient’s neck two times. Makes sure to cut end of the tape on an angle.
7. Dons sterile gloves (or sterile on dominant and clean on nondominant hand); keeps the glove on the dominant hand sterile. Handles the sterile supplies with the dominant hand only.
8. With the nondominant hand removes the oxygen source, if the patient has been receiving supplemental oxygen.
9. Unlocks and removes the inner cannula with the nondominant hand and cares for it accordingly:
a. Disposable Inner Cannula: Disposes of the inner cannula in the biohazard receptacle according to agency policy.
b. Reusable Inner Cannula: Places the inner cannula into the basin filled with hydrogen peroxide.
10. Attaches the oxygen source to the outer cannula, if possible.
11. Cares for the inner cannula:
a. Variation: Disposable Inner Cannula: Picks up the new disposable inner cannula, holding it by the outer locking portion.
b. Reusable Inner Cannula:
· 1) Picks up the reusable inner cannula from the container of hydrogen peroxide and scrubs it with the sterile nylon brush, using the dominant hand.
· 2) Immerses the inner cannula in the container of sterile normal saline and agitates it until it is thoroughly rinsed.
· 3) Taps the inner cannula against the side of the container to remove excess fluid.
12. Removes the oxygen source, using nondominant hand, (if the patient requires supplemental oxygen) and reinserts the inner cannula into the patient’s tracheostomy in the direction of the curvature.
13. Following manufacturer instructions, locks the inner cannula in place securely.
14. Reattaches the oxygen source, if indicated.
15. Cleans the stoma under the faceplate with the cotton-tipped applicators saturated with hydrogen peroxide, using a circular motion from the stoma site outward.
16. Uses each applicator only once and then discards it.
17. Cleans the top surface of the faceplate and the skin around it with the gauze pads saturated with hydrogen peroxide. Uses each gauze pad only once, and then discards it.
18. Repeats steps 15, 16, and 17, using the cotton-tipped applicators and gauze pads saturated with normal saline.
19. Dries the skin and outer cannula surfaces by patting them lightly with the remaining dry gauze pads.
20. Removes soiled tracheostomy stabilizers:
a. Variation: Velcro Tracheostomy Holder: With an assistant stabilizing the tracheostomy tube, disengages the Velcro on both sides of the soiled holder and removes it gently from the eyes of the faceplate. Discards the Velcro holder in the nearest biohazard receptacle.
b. Variation: Twill Tape Tracheostomy Ties: With the assistant stabilizing the tracheostomy tube, cuts the soiled tracheostomy ties using bandage scissors. Avoids cutting the tube of the tracheostomy balloon. Removes the ties gently from the eyes of the faceplate and discards them in the nearest biohazard receptacle.
21. Has the patient flex his neck and applies new tracheostomy stabilizers.
a. Variation: Velcro Tracheostomy Holder:
· 1) Unfastens the Velcro; threads one end of the tracheostomy holder through the eyelet of the faceplate, and fastens the Velcro.
· 2) Brings the holder around the back of the patient’s neck and threads the remaining end of the tracheostomy holder through the empty eyelet of the faceplate. Fastens the Velcro, making sure the holder fits securely.
· 3) Places one finger under the holder to make sure the holder is securing the tracheostomy effectively, but is not too tight.
b. Variation: Using Twill Tape:
· 1) Threads one end of the twill tape into one of the eyelets on the tracheostomy faceplate; continues to thread the twill tape through the eyelet, bringing both ends of the tape together.
· 2) Brings both ends of the twill tape around the back of the patient’s neck.
· 3) Threads the end of the twill tape that is closest to the patient’s neck through the back of the eyelet on the faceplate.
· 4) Has the assistant place one finger under the tape while tying the two ends together in a square knot.
22. Inserts a precut, sterile tracheostomy dressing under the faceplate and new tracheostomy stabilizers.
23. Disposes of used equipment/supplies in the appropriate biohazard receptacle, according to agency policy.
Monitoring Pulse Oximetry (Arterial Oxygen Saturation)
1. Chooses a sensor appropriate for the patient’s age, size, and weight; and the desired location.
2. If the patient is allergic to adhesive, uses a clip-on probe sensor. Uses a nasal sensor if the patient’s peripheral circulation is compromised.
3. Prepares the site by cleansing and drying.
4. If the finger is the desired monitoring location, removes nail polish or an acrylic nail, if present.
5. Removes the protective backing if using a disposable probe sensor that contains adhesive.
6. Attaches the probe sensor to the chosen site. Makes sure that the photo-detector and light-emitting diodes on the probe sensor face each other.
7. If a clip-on probe sensor is used, warns the patient that he may feel a pinching sensation.
8. Connects the sensor probe to the oximeter and turns it on.
9. Checks the pulse rate displayed on the oximeter to see if it correlates with the patient’s radial pulse.
10. Reads the SaO2 measurement on the digital display when it reaches a constant value, usually in 10 to 30 seconds.
11. Sets and turns on the alarm limits for SaO2 and pulse rate, according to manufacturer instructions, patient condition, and agency policy, if continuous monitoring is necessary.
12. Obtains readings as ordered or indicated by the patient’s respiratory status.
13. Rotates the probe site every 4 hours for an adhesive probe sensor and every 2 hours for a clip-on probe sensor, if continuous monitoring is indicated.
14. Removes the probe sensor and turns off the oximeter when monitoring is no longer necessary.
Caring for a Patient with Chest Tubes (Disposable Water-Seal System)
1. Obtains and prepares the prescribed drainage system.
a. Disposable water-seal system without suction.
1) Removes the cover on the water-seal chamber and, using the funnel provided, fills the second (water-seal) chamber with sterile water or normal saline. Fills to the 2-cm mark, or as indicated.
2) Replaces the cover on the water-seal chamber.
b. Disposable water-seal system with suction.
1) Removes the cover on the water-seal chamber and, using the funnel provided, fills the water-seal chamber (second chamber) with sterile water or normal saline to the 2-cm mark.
2) Adds sterile water or normal saline solution to the suction-control chamber. Adds the amount of fluid specified by the physician order, typically
3) Attaches the tubing from the suction-control chamber to the connecting tubing attached to the suction source.
2. Positions the patient according to the indicated insertion site.
3. Dons a mask, gown, and sterile gloves.
4. Provides support to the patient while the physician prepares the sterile field, anesthetizes the patient, and inserts and sutures the chest tube.
5. As soon as the chest tube is inserted, attaches it to drainage system using a connector.
6. Using sterile technique, wraps petroleum gauze around the chest tube insertion site.
7. Places a precut, sterile drain dressing over the petroleum gauze.
8. Places a second sterile, precut, drain dressing over the first drain dressing with the opening facing in the opposite direction from the first one.
9. Places a large drainage dressing (“ABD”) over the two precut drain dressings.
10. Secures the dressing in place with 2-inch silk tape, making sure to cover the dressing completely.
11. Writes date, time, and initials on the dressing.
12. Using the spiral taping technique, wraps 1-inch silk tape around the chest tube starting above the connector and continuing below the connector. Reverses the wrapping by taping back up the tubing (using the spiral technique) until above the connector.
13. Cuts an 8-inch-long piece of 2-inch tape. Loops one end around the top portion of the drainage tube and secures the remaining end of the tape to the chest tube dressing.
14. If suction is prescribed, adjusts the suction source until gentle bubbling occurs in the suction-control chamber. If suction is not prescribed, leaves the suction tubing on the drainage system open.
15. Makes sure that the drainage tubing lies with no kinks from the chest tube to the drainage chamber.
16. Prepares the patient for a portable chest x-ray.
17. Places two rubber-tipped clamps at the patient’s bedside for special situations (safety measure).
18. Places a petroleum gauze dressing at the bedside in case the chest tube becomes dislodged.
19. Keeps a spare disposable drainage system at the patient’s bedside.
20. Positions patient for comfort, as indicated.
21. Maintains chest tube and drainage system patency by:
a. Making sure the drainage tubing is free of kinks.
b. Inspecting the air vent in the drainage system to make sure it is patent.
c. Making sure the drainage system is located below the insertion site.
Performing Cardiopulmonary Resuscitation, One- and Two-Person
We have intentionally not provided a checklist for this procedure because students should be certified in CPR, using official tests and materials. As a quick review, but not as a “check-off,” you can use the critical aspects, that follow:
Critical Aspects
1. Establish whether the patient is unresponsive (shake and shout, “Are you OK?”)
2. Activate the emergency response system immediately if the patient is an adult. If you are alone and the patient is an infant or child, perform CPR for 1 minute then activate the emergency response system.
3. Carefully place the patient on a hard surface. Logroll the patient if a cervical spine injury is suspected. If the patient is in a hospital bed, place a CPR board under the patient’s back.
4. Properly position yourself.
5. A—Airway. Open the patient’s airway. Use either the head tilt-chin lift maneuver or the jaw thrust maneuver.
6. B—Breathing. Check for breathing. (Place your ear over the patient’s mouth and nose. Look, listen, and feel for breathing for no longer than 10 seconds.) If the patient is breathing, continue to hold the airway open. If the patient is not breathing, administer 2 slow breaths.
7. C—Circulation. Check for signs of circulation. Use the carotid pulse in adults and children, and the brachial or femoral pulse in infants. Assess for a pulse for 5 to 10 seconds. Also check for other signs of circulation, such as movement.
8. If signs of circulation are absent, correctly position your hands and begin chest compressions.
9. Continue CPR for 4 cycles then reassess pulse.
10. Stop CPR if the patient responds, regains an adequate pulse and begins to breathe, you are too exhausted to continue; or signs of death are obvious.
Applying an External (Condom) Catheter
1. Assesses skin of the penis.
2. Uses clean technique throughout (medical asepsis).
3. Prepares the leg bag or bedside drainage bag for attachment to the condom catheter by removing it from the packaging and placing the end of the connecting tubing near the perineal area.
4. Rolls the condom catheter outward onto itself to prepare for rolling up and onto the penis.
5. Places the patient in the supine position. For patients whose respiratory efforts may be impaired, raises the head of the bed to 30°.
6. Folds down the bedcovers to expose the genitalia and drapes the patient, using the bath blanket.
7. Washes hands.
8. Dons clean procedure gloves.
9. Gently cleanses the penis with soap and water. Rinses and dries thoroughly.
10. If the penis is uncircumcised, retracts the foreskin, cleanses the glans and replaces the foreskin.
11. Clips excess hair along the shaft of the penis, unless contraindicated by policy or patient’s condition.
12. Washes hands; changes procedure gloves.
13. Measures circumference of the penis. Ensures catheter is appropriately sized.
14. Applies skin prep (according to agency policy) and allows it to dry. (Some condom catheters require that a special adhesive strip be placed onto the penis prior to application of the condom; follows manufacturer’s directions.)
15. Holding penis in nondominant hand, with dominant hand places the condom at the end of the penis and slowly unrolls it up and along the shaft.
16. Leaves 1 to
17. Secures condom catheter in place on the penis.
a. Ensures that the condom is not twisted.
b. For condom catheters with internal adhesive, gently grasps the penis and compresses so that the entire shaft comes in contact with the condom.
c. For condom catheters with external adhesives strips, wraps the strip around the outside of the condom in a spiral direction, taking care not to overlap the ends.
18. Does not use regular bandage tape to hold a condom catheter in place.
19. Assesses the proximal end of the condom catheter. If there is a large portion of the condom still rolled above the adhesive strip, clips the roll.
20. Attaches the tube end of the condom catheter to a drainage system, making sure there are no kinks in the tubing.
21. Secures the drainage tubing to the patient’s thigh using tape or a commercial leg strap (follow facility protocol)..
22. Covers the patient.
23. Removes gloves and washes the hands.
Inserting a Straight Urinary Catheter (Male)
1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.
2. Selects a catheter kit that contains lubricant in a prefilled syringe.
3. Provides good lighting; takes a procedure lamp to the bedside if necessary.
4. Works on the right side of the bed if right-handed; the left side, if left-handed.
5. Places patient supine, legs straight and slightly apart.
6. If patient is confused or unable to follow directions, obtains help.
7. Drapes patient. Covers upper body with blanket; folds linens down to expose the penis.
8. Dons clean procedure gloves and washes the penis and perineal area with soap and water; dries gently.
9. If using 2% Xylocaine gel for the procedure, uses a syringe to insert it into the urethra.
10. Removes and discards gloves.
11. Washes hands.
12. Organizes the work area:
a. Bedside or over-bed table within nurse’s reach.
b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.
c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.
13. Applies sterile drape(s) and underpad.
Variation: Waterproof underpad packed as top item in the kit.
a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.
b. Allows drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down across top of patient’s thighs.
c. Dons sterile gloves (from kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.)
d. Picks up fenestrated drape; allows it to unfold without touching other objects; places hole over the penis.
Variation: Sterile gloves packed as top item in the kit. Uses the following steps instead of Steps 12 a-d:
e. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.
f. Grasps the edges of the sterile underpad and places it shiny side down across the top of the patient’s thighs.
g. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile.
h. Places fenestrated drape so that hole is over the penis.
14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.
a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)
b. Lays forceps near cotton balls (omit step if kit includes swabs).
c. Opens specimen container if a specimen is to be collected.
d. Removes any unneeded supplies (e.g., specimen container) from the field.
e. Expresses a small amount of sterile lubricant into the kit tray; lubricates the first 1 to
15. With nondominant hand, reaches through the opening in the fenestrated drape and grasps the penis, taking care not to contaminate the surrounding drape. If penis is uncircumcised, retracts foreskin with nondominant hand to expose the meatus.
16. If the foreskin accidentally falls back over the meatus, or if the nurse drops the penis during cleansing, repeats the procedure.
17. Continuing to hold the penis with the nondominant hand, holds forceps in dominant hand and picks up a cotton ball.
18. Beginning at the meatus, cleanses the glans in a circular motion in ever-widening circles and partially down the shaft of the penis.
19. Repeats with at least one more cotton ball.
20. Discards cotton balls as they are used; does not move them across the open, sterile kit and field.
21. Maintaining sterile technique, places the plastic urine receptacle close enough to the urinary meatus for the end of the catheter to rest inside the container as the urine drains (e.g., places container between patient’s thighs)
22. Using the nondominant hand, holds the penis gently but firmly at a 90° angle to the body, exerting gentle traction.
23. Gently inserts the tip of the prefilled syringe into the urethra and instill the lubricant. (If the kit contains only a single packet of lubricant and if no other kits are available, lubricates 5 to
24. With the dominant hand, holds the catheter
25. Asks the patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.
26. Continues gentle insertion of catheter until urine flows. This is about 7 to
27. If resistance is felt, withdraws the catheter; does not force the catheter.
28. Continues to hold the penis and catheter securely in hand while the urine drains from the bladder.
29. If a urine specimen is to be collected, uses dominant hand to place the specimen container into the flow of urine; caps container using sterile technique.
30. When the flow of urine has ceased and the bladder has been emptied, pinches the catheter and slowly withdraws it from the meatus.
31. Discards catheter.
32. Removes the urine-filled receptacle and sets aside to be emptied when the procedure is finished.
33. Cleanses and dries patient’s penis and perineal area as needed; replaces foreskin over end of penis.
34. Removes gloves; washes hands.
35. Returns patient to a position of comfort.
36. Discards supplies in appropriate receptacle.
Collecting a Clean-Catch Urine Specimen
NOTE:
If patient is can do self care, instructs patient in the following steps. If not, performs them for the patient.
1. Assists patient to toilet, commode, or onto bedpan.
2. Opens prepackaged kit, if available, and removes contents.
3. Washes hands and dons clean procedure gloves.
4. Instructs patient to cleanse around the urinary meatus if able; if not able, performs cleansing.
5. Asks patient to spread her legs; washes perineal area with warm water and mild soap.
6. Opens the antiseptic towelette in the prepackaged kit. If there is no kit, pours antiseptic solution over cotton balls.
7. Cleanses perineal area in a front-to-back direction; cleanses over the urinary meatus.
8. Cleans the perineal area at least twice.
9. Uses each towelette area or each cotton ball only once.
10. If penis is uncircumcised, retracts the foreskin back from the end of the penis.
11. Uses towelette from the prepackaged kit or pours antiseptic solution over cotton balls.
12. Grasps the penis gently with one hand; with the other hand, cleanses the meatus in a circular motion from the meatus outward; cleanses for a few inches down the shaft of the penis.
13. Cleanses around the meatus at least twice, using each area of the towelette or each cotton ball only once.
NOTE: Some lab manuals recommend rinsing the antiseptic solution from the meatus to prevent contamination of the specimen with antiseptic.
14. Removes gloves; washes hands; dons a second pair of clean procedure gloves.
15. For the patient using a bedpan, raises the head of the bed to a semi-Fowler’s position.
16. Opens the sterile specimen container; does not touch the inside of the lid or the container.
17. Holding the container near the meatus, instructs the patient to begin voiding.
a. For female patient: Holds the labia apart during this step (or teaches self-care patients to do so).
b. For the male patient unable to assist, holds the penis.
18. Allows a small stream of urine to pass, then places the specimen container into the stream.
19. Does not let the end of the male patient’s penis touch the inside of the container; does not touch the female perineum with the container.
20. Collects approximately 30–60 mL of urine.
21. Removes container from the stream and allows the patient to finish emptying the bladder.
22. For the male patient who is uncircumcised, replaces the foreskin over the glans when the procedure is finished.
23. Carefully replaces the container lid, touching only the outside of the cap and container.
24. Cleanses the outside of the container of urine, if necessary.
25. Labels the container with the correct patient information (in many institutions these are preprinted or bar-coded).
26. Places the container in a facility specific carrier (usually a plastic bag) for transport to the lab.
27. Removes gloves and washes hands. If the specimen has been obtained from a patient on a bedpan, leaves gloves on until the bedpan has been removed, emptied, and stored properly.
28. Assists patient back to bed or removes bedpan.
29. Transports the specimen to the lab in a timely manner.
Inserting an Indwelling Urinary Catheter (Female)
1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.
2. Provides good lighting; takes a procedure lamp to the bedside if necessary.
3. Works on the right side of the bed if right-handed; the left side, if left-handed.
4. Assists to dorsal recumbent position (knees flexed, feet flat on the bed). Instructs patient to relax her thighs and let them rotate externally (if patient is able to cooperate).
Alternatively, uses Sims’ position (side-lying with upper leg flexed at hip.
5. If patient is confused, unable to follow directions, or unable to hold her legs in correct position, obtains help.
6. Drapes patient. If dorsal recumbent position is used, folds blanket in a diamond shape, wraps corners around legs, anchors under feet, and folds upper corner down over perineum. If in Sims’ position, drapes so that rectal area is covered.
7. Dons clean procedure gloves and washes the perineal area with soap and water; dries perineal area.
8. While washing perineum, locates the urinary meatus.
9. Removes and discards gloves.
10. Washes hands.
11. Organizes the work area:
a. Bedside or over-bed table within nurse’s reach.
b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.
c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.
d. Positions the procedure light or has assistant hold a flashlight.
e. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.
12. Applies sterile drape(s) and underpad.
Variation: Waterproof underpad packed as top item in the kit.
f. Removes the underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.
g. Touching only the corners and shiny side, places the drape flat on the bed, shiny side down, and tucks the top edge under the patient’s buttocks.
h. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.
i. Dons sterile gloves (from kit). (Touching only the glove package, removes it from sterile kit before donning gloves).
j. Picks up fenestrated drape; allows it to unfold without touching other objects; places over perineum with the hole over the labia.
Variation: Sterile gloves packed as top item in the kit.
Uses the following steps instead of Steps 12 a-j:
k. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.
l. Grasps the edges of the sterile underpad and folds the entire edge down 2.5 to
m. Asks patient to raise her hips slightly if she is able.
n. Slides the drape under patient’s buttocks without contaminating the gloves.
o. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Creates “cuff” to protect gloves, as in step 12-l.
p. Places fenestrated drape so that hole is over labia.
13. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.
a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)
b. Lays forceps near cotton balls (omits step if using swabs).
c. Opens specimen container if a specimen is to be collected.
d. Removes any unneeded supplies (e.g., specimen container) from the field.
e. Removes plastic covering from catheter.
f. Opens package and expresses sterile lubricant into the kit tray; lubricates the first 1 to
g. Removes plastic cover from catheter. Attaches the saline-filled syringe to the side port of the catheter and inflates the balloon.
h. Deflates balloon and returns catheter to the kit, leaving the syringe connected to the port.
14. Touching only the sterile box or inside of the wrapping, places the sterile catheter kit (tray and box) down onto the sterile field between the patient’s legs.
15. If the drainage bag is preconnected to the catheter itself, leaves the bag on or near the sterile field until after the catheter is inserted.
16. Cleanses the urinary meatus.
a. Places nondominant hand above the labia and with the thumb and forefinger spreads the patient’s labia, pulls up (or anteriorly) at the same time, to expose the urinary meatus.
b. Holds this position throughout the procedure—firm pressure is necessary.
c. If the labia slip back over the urinary meatus, considers it contaminated and repeats cleansing procedure.
d. With dominant hand, picks up a wet cotton ball (or swab), using forceps, and cleanses perineal area, taking care not to contaminate the sterile glove.
e. Uses one stroke for each area.
f. Wipes from front to back..
g. Uses a new cotton ball for each area.
h. Cleanses in this order: outside far labium majus, outside near labium majus, inside far labium, inside near labium, and directly down the center over the urinary meatus.
If there are only 3 cotton balls in the kit, labia majora should be washed with soap and water initially; and in this step, cleanses only the inside far labium majus, inside near labium, and down center directly over the meatus.
17. Discards used cotton balls or swabs as they are used; does not move them across the open, sterile kit and field.
18. With the dominant hand, holds the catheter approximately
19. Asks the woman to bear down as though she is trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.
20. Continues gentle insertion of catheter until urine flows. This is about 2 to
21. If resistance is felt, twists the catheter slightly or applies gentle pressure; does not force the catheter.
22. If the catheter touches the labia or nonsterile linens, or is inadvertently inserted in the vagina, considers it contaminated and inserts a new, sterile catheter.
23. If catheter is inadvertently inserted into the vagina, leaves the contaminated catheter in the vagina while inserting the new one into the meatus.
24. Continues to hold the catheter securely with the dominant hand; after urine flows, stabilizes the catheter’s position in the urethra and uses the nondominant hand to pick up the saline-filled syringe and inflate the catheter balloon.
25. If the patient complains of severe pain upon inflation of the balloon, the catheter is probably in the urethra. Allows the water to drain out of the balloon and repositions the catheter by advancing it
26. Connects the drainage bag to the end of the catheter if it is not already preconnected. Hangs the drainage bag on the side of the bed, below the level of the bladder.
27. Using a tape or a catheter strap, secures the catheter to the thigh.
28. Cleanses patients perineal area as needed, and dries.
29. Removes gloves; washes hands.
30. Returns patient to a position of comfort.
31. Discards supplies in appropriate receptacle.
Continuous Bladder Irrigation
1. Uses sterile irrigation solution, warmed to room temperature.
2. Never disconnects the drainage tubing from the catheter.
3. If not already present, inserts a 3-way (triple lumen) indwelling catheter.
4. Prepares the irrigation fluid and tubing:
a. Closes the clamp on the connecting tubing.
b. Spikes the tubing into the appropriate portal on the irrigation solution container, using aseptic technique.
c. Inverts the container and hangs it on the IV pole.
d. Removes protective cap from the distal end of the connecting tubing; holds end of tubing over a sink and opens the roller clamp slowly, allowing solution to completely fill the tubing. Recaps the tubing.
5. Dons clean procedure gloves.
6. Drapes patient so that only the connection port on the indwelling catheter is visible.
7. Places a sterile barrier under the irrigation port on a 3-way catheter.
8. Removes any plug from the port. Connects end of irrigation tubing to the side port of the catheter, using aseptic technique. Pinches or clamps tubing to prevent leakage of urine.
9. Before beginning flow of irrigation solution, empties urine from the bedside drainage bag and documents amount.
10. Removes gloves; washes hands.
11. Covers the patient and makes him comfortable.
12. Opens the roller clamp on the tubing and regulates the flow of the irrigation solution to meet the desired outcome for the irrigation (e.g., the goal of continuous bladder irrigation for patients who have had a transurethral resection of the prostate is to keep the urine light pink to clear).
13. Monitors flow rate for 1 to 2 minutes to ensure accuracy.
Inserting an Indwelling Urinary Catheter (Male)
1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.
2. Selects a catheter kit that contains lubricant in a prefilled syringe.
3. Provides good lighting; takes a procedure lamp to the bedside if necessary.
4. Works on the right side of the bed if right-handed; the left side, if left-handed.
5. Places patient supine, legs straight and slightly apart.
6. If patient is confused or unable to follow directions, obtains help.
7. Drapes patient. Covers upper body with blanket; folds linens down to expose the penis.
8. Dons clean procedure gloves and washes the penis and perineal area with soap and water; dries gently.
9. If using 2% Xylocaine gel for the procedure, uses a syringe and inserts it into the urethra.
10. Removes and discards gloves.
11. Washes hands.
12. Organizes the work area:
a. Bedside or over-bed table within nurse’s reach.
b. Opens sterile catheter kit and places on bedside table, without contaminating the inside of the wrap.
c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.
13. Applies sterile drape(s) and underpad.
Variation: Waterproof underpad packed as top item in the kit.
a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.
b. Allows drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down across top of patient’s thighs.
c. Dons sterile gloves (from kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.)
d. Picks up fenestrated drape; allows it to unfold without touching other objects; places hole over the penis.
Variation: Sterile gloves packed as top item in the kit.
Uses the following steps instead of Steps 12 a–d:
e. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.
f. Grasps the edges of the sterile underpad and places it shiny side down across the top of the patient’s thighs.
g. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile.
h. Places fenestrated drape so that hole is over the penis.
14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.
a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)
b. Lays forceps near cotton balls (omit step if using swabs).
c. Opens specimen container if a specimen is to be collected.
d. Removes any unneeded supplies (e.g., specimen container) from the field.
e. Expresses a small amount of sterile lubricant into the kit tray; lubricates the first 1 to
f. Attaches the saline-filled syringe to the side port of the catheter and checks balloon by inflating; deflates balloon and returns it and the catheter to the kit. Leaves syringe attached to catheter.
15. Touching only the kit or inside of the wrapping, places the sterile catheter kit down onto the sterile field between or on top of the patient’s thighs.
16. If the drainage bag is preconnected to the catheter, leaves the bag on the sterile field until after the catheter is inserted.
17. With nondominant hand, reaches through the opening in the fenestrated drape and grasps the penis, taking care not to contaminate the surrounding drape. If penis is uncircumcised, retracts foreskin to expose the meatus.
18. If the foreskin accidentally falls back over the meatus, or if the nurse drops the penis during cleansing, repeats the procedure.
19. Continuing to hold the penis with the nondominant hand, holds forceps in dominant hand and picks up a cotton ball.
20. Beginning at the meatus, cleanses the glans in a circular motion in ever-widening circles and partially down the shaft of the penis.
21. Repeats with at least one more cotton ball.
22. Discards cotton balls or swabs as they are used; does not move them across the open, sterile kit and field.
23. Using the nondominant hand, holds the penis gently but firmly at a 90° angle to the body, exerting gentle traction.
24. Gently inserts the tip of the prefilled syringe into the urethra and instill the lubricant. (If the kit contains only a single packet of lubricant and if no other kits are available, then lubricates 5 to
25. With the dominant hand, holds the catheter
26. Asks the patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.
27. Continues gentle insertion of catheter until urine flows. This is about 7 to
28. If resistance is felt, withdraws the catheter; does not force the catheter.
29. After urine flows, stabilizes the catheter’s position in the urethra with nondominant hand; uses dominant hand to pick up saline-filled syringe and inflate catheter balloon.
30. If patient complains of severe pain upon inflation of the balloon, the balloon is probably in the urethra. Allows the water to drain out of the balloon, and advances the catheter
31. If it is not preconnected, connects the drainage bag to the end of the catheter.
32. Hangs the drainage bag on the side of the bed below the level of the bladder.
33. Using tape or a catheter strap, secures the catheter to the thigh or the abdomen.
34. Cleanses patient’s penis and perineal area as needed, and dries. Ensures that foreskin is no longer retracted.
35. Removes gloves; washes hands.
36. Returns patient to a position of comfort.
37. Discards supplies in appropriate receptacle.
Inserting a Straight Urinary Catheter (Female)
1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.
2. Provides good lighting; takes a procedure lamp to the bedside if necessary.
3. Works on the right side of the bed if right-handed; the left side, if left-handed.
4. Assists to dorsal recumbent position (knees flexed, feet flat on the bed). Instructs patient to relax her thighs and let them rotate externally (if patient is able to cooperate).
Alternatively, uses Sims’ position (side-lying with upper leg flexed at hip.
5. If patient is confused, unable to follow directions, or unable to hold her legs in correct position, obtains help.
6. Drapes patient. If dorsal recumbent position is used, folds blanket in a diamond shape, wraps corners around legs, anchors under feet, and folds upper corner down over perineum. If in Sims’ position, drapes so that rectal area is covered.
7. Dons clean procedure gloves and washes the perineal area with soap and water; dries perineal area.
8. While washing perineum, locates the urinary meatus (for women).
9. Removes and discards gloves.
10. Washes hands.
11. Organizes the work area:
a. Bedside or over-bed table within nurse’s reach.
b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.
c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.
d. Positions the procedure light or has assistant hold a flashlight.
12. Lifts corner of privacy drape (e.g., bath blanket) to expose the perineum.
13. Applies sterile drape(s) and underpad.
Variation: Waterproof underpad packed as top item in the kit.
e. Removes the underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.
f. Touching only the corners and shiny side, places the drape flat on the bed, shiny side down, and tucks the top edge under the patient’s buttocks.
g. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.
h. Dons sterile gloves (from kit). (Touching only the glove package, removes it from sterile kit before donning gloves).
i. Picks up fenestrated drape; allows it to unfold without touching other objects; places over perineum with the hole over the labia.
Variation: Sterile gloves packed as top item in the kit.
Uses the following steps instead of Steps 12 a–i:
j. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.
k. Grasps the edges of the sterile underpad and folds the entire edge down 2.5 to
l. Asks patient to raise her hips slightly if she is able.
m. Slides the drape under patient’s buttocks without contaminating the gloves.
n. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Creates “cuff” to protect gloves, as in step 12(k).
o. Places fenestrated drape so that hole is over labia.
14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.
a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)
b. Lays forceps near cotton balls.
c. Opens specimen container if a specimen is to be collected.
d. Removes any unneeded supplies (e.g., specimen container) from the field.
e. Opens the packet of sterile lubricant and squeezes it into the kit tray.
f. Lubricates the first 1 to
15. Touching only the kit or the inside of the wrapping, places the sterile catheter kit down onto the sterile field between the patient’s legs.
16. Cleanses the urinary meatus.
a. Places nondominant hand above the labia and with the thumb and forefinger spreads the patient’s labia, pulls up (or anteriorly) at the same time, to expose the urinary meatus.
b. Holds this position throughout the procedure—firm pressure is necessary.
c. If the labia slip back over the urinary meatus, considers it contaminated and repeats cleansing procedure.
d. Using forceps, with dominant hand, picks up a wet cotton ball and cleanses perineal area, taking care not to contaminate the sterile glove.
e. Uses one stroke for each area.
f. Wipes from front to back.
g. Uses a new cotton ball for each area.
h. Cleanses in this order: outside far labium majus, outside near labium majus, inside far labium, inside near labium, and directly down the center over the urinary meatus.
(Some kits have only 3 cotton balls, so the order would be inside far labium, inside near labium, and directly down the center; the outside labia majora would have already been cleansed with soap and water.)
17. Discards used cotton balls as they are used; does not move them across the open, sterile kit and field.
18. Maintaining sterile technique, places the urine receptacle close enough to the urinary meatus for the end of the catheter to rest inside the container as the urine drains (
19. Asks the woman to bear down as though she is trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.
20. Continues gentle insertion of catheter until urine flows. This is about 2 to
21. If resistance is felt, twists the catheter slightly or applies gentle pressure; does not force the catheter.
22. If the catheter touches the labia or nonsterile linens, or is inadvertently inserted in the vagina, considers it contaminated and inserts a new, sterile catheter.
23. If catheter is inadvertently inserted into the vagina, leaves the contaminated catheter in the vagina while inserting the new one into the meatus.
24. Continues to hold the catheter securely with the nondominant hand while urine drains from the bladder.
25. If a urine specimen is to be collected, uses dominant hand to place the specimen container into the flow of urine; caps container using sterile technique.
26. When the flow of urine has ceased and the bladder has been emptied, pinches the catheter and slowly withdraws it from the meatus.
27. Discards catheter, observing universal precautions.
28. Removes the urine-filled receptacle and sets aside to be emptied when the procedure is finished.
29. Cleanses patient’s perineal area as needed, and dries.
30. Removes gloves; washes hands.
31. Returns patient to a position of comfort.
32. Discards supplies in appropriate receptacle.
Intermittent Bladder or Catheter Irrigation
1. Uses sterile irrigation solution, warmed to room temperature.
2. Never disconnects the drainage tubing from the catheter.
3. If not already present, inserts a 3-way (triple lumen) indwelling catheter.
Intermittent Irrigation, Three-way (Triple Lumen) Indwelling catheter
4. Prepares the irrigation fluid and tubing:
a. Closes the clamp on the connecting tubing.
b. Spikes the tubing into the appropriate portal on the irrigation solution container, using aseptic technique.
c. Inverts the container and hangs it on the IV pole.
d. Removes protective cap from the distal end of the connecting tubing; holds end of tubing over a sink and opens the roller clamp slowly, allowing solution to completely fill the tubing. Recaps the tubing.
5. Dons clean procedure gloves.
6. Drapes patient so that only the connection port on the indwelling catheter is visible.
7. Prior to beginning the flow of irrigation solution, empties any urine that may be in the bedside drainage bag and documents amount.
8. Determines whether the irrigant is to remain in the bladder for any length of time. If irrigant is to remain in the bladder for a certain time period, clamps the drainage tubing for that time.
9. Slowly opens roller clamp on the irrigation tubing.
10. Instills or irrigates with the prescribed amount of irrigant.
11. When the correct amount of irrigant has been used and/or the goals of the irrigation have been met, closes the roller clamp on the irrigation tubing, leaving the tubing connected to the catheter for use during the next irrigation.
12. Removes gloves; washes hands.
13. Makes patient comfortable.
14. Dons clean procedure gloves; empties any urine currently in the bedside drainage bag.
15. Drapes patient so that only the specimen removal port on the drainage tubing is exposed.
16. Places a waterproof drape beneath the exposed port.
17. Opens the sterile irrigation supplies. Pours approximately 100 mL of the irrigating solution into the sterile container, using aseptic technique.
18. Swabs specimen removal port with antiseptic swab.
19. Draws irrigation solution into the syringe. (For catheter irrigation, use a total of 30–40 mL; for bladder irrigation the amount is usually 100– 200 mL.)
20. Inserts the needle into the specimen port. Points the needle toward the bladder.
21. Holds the specimen port with the fingers; does not lay the tubing/port in the palm of the hand when accessing the port.
22. Clamps drainage tubing distal to the specimen port.
23. Injects the solution, holding the specimen port slightly above the level of the bladder.
24. If meets resistance, has patient turn slightly and attempts a second time. If resistance continues, stops the procedure and notifies the physician.
25. When the irrigant has been injected, withdraws the needle. Refills the syringe if necessary.
26. Does NOT recap the needle. If necessary to repeat the irrigation, rests the needle end of the syringe in the irrigation solution container.
27. Unclamps the drainage tubing and allows the irrigant and urine to flow into the bedside drainage bag by gravity. (If the solution is to remain in the bladder for a prescribed time, leaves the tubing clamped for that time period.)
28. Repeats the procedure as necessary until the prescribed amount has been instilled, or until the goal of the irrigation is met. (e.g. removal of clots, mucus, urine flowing freely, etc.)
29. Removes gloves, washes hands.
30. Returns patient to a position of comfort.
Applying an External (Condom) Catheter
1. Assesses skin of the penis.
2. Uses clean technique throughout (medical asepsis).
3. Prepares the leg bag or bedside drainage bag for attachment to the condom catheter by removing it from the packaging and placing the end of the connecting tubing near the perineal area.
4. Rolls the condom catheter outward onto itself to prepare for rolling up and onto the penis.
5. Places the patient in the supine position. For patients whose respiratory efforts may be impaired, raises the head of the bed to 30°.
6. Folds down the bedcovers to expose the genitalia and drapes the patient, using the bath blanket.
7. Washes hands.
8. Dons clean procedure gloves.
9. Gently cleanses the penis with soap and water. Rinses and dries thoroughly.
10. If the penis is uncircumcised, retracts the foreskin, cleanses the glans and replaces the foreskin.
11. Clips excess hair along the shaft of the penis, unless contraindicated by policy or patient’s condition.
12. Washes hands; changes procedure gloves.
13. Measures circumference of the penis. Ensures catheter is appropriately sized.
14. Applies skin prep (according to agency policy) and allows it to dry. (Some condom catheters require that a special adhesive strip be placed onto the penis prior to application of the condom; follows manufacturer’s directions.)
15. Holding penis in nondominant hand, with dominant hand places the condom at the end of the penis and slowly unrolls it up and along the shaft.
16. Leaves 1 to
17. Secures condom catheter in place on the penis.
a. Ensures that the condom is not twisted.
b. For condom catheters with internal adhesive, gently grasps the penis and compresses so that the entire shaft comes in contact with the condom.
c. For condom catheters with external adhesives strips, wraps the strip around the outside of the condom in a spiral direction, taking care not to overlap the ends.
18. Does not use regular bandage tape to hold a condom catheter in place.
19. Assesses the proximal end of the condom catheter. If there is a large portion of the condom still rolled above the adhesive strip, clips the roll.
20. Attaches the tube end of the condom catheter to a drainage system, making sure there are no kinks in the tubing.
21. Secures the drainage tubing to the patient’s thigh using tape or a commercial leg strap (follow facility protocol)..
22. Covers the patient.
23. Removes gloves and washes the hands.
Inserting a Straight Urinary Catheter (Male)
1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.
2. Selects a catheter kit that contains lubricant in a prefilled syringe.
3. Provides good lighting; takes a procedure lamp to the bedside if necessary.
4. Works on the right side of the bed if right-handed; the left side, if left-handed.
5. Places patient supine, legs straight and slightly apart.
6. If patient is confused or unable to follow directions, obtains help.
7. Drapes patient. Covers upper body with blanket; folds linens down to expose the penis.
8. Dons clean procedure gloves and washes the penis and perineal area with soap and water; dries gently.
9. If using 2% Xylocaine gel for the procedure, uses a syringe to insert it into the urethra.
10. Removes and discards gloves.
11. Washes hands.
12. Organizes the work area:
a. Bedside or over-bed table within nurse’s reach.
b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.
c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.
13. Applies sterile drape(s) and underpad.
Variation: Waterproof underpad packed as top item in the kit.
a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.
b. Allows drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down across top of patient’s thighs.
c. Dons sterile gloves (from kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.)
d. Picks up fenestrated drape; allows it to unfold without touching other objects; places hole over the penis.
Variation: Sterile gloves packed as top item in the kit. Uses the following steps instead of Steps 12 a-d:
e. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.
f. Grasps the edges of the sterile underpad and places it shiny side down across the top of the patient’s thighs.
g. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile.
h. Places fenestrated drape so that hole is over the penis.
14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.
a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)
b. Lays forceps near cotton balls (omit step if kit includes swabs).
c. Opens specimen container if a specimen is to be collected.
d. Removes any unneeded supplies (e.g., specimen container) from the field.
e. Expresses a small amount of sterile lubricant into the kit tray; lubricates the first 1 to
15. With nondominant hand, reaches through the opening in the fenestrated drape and grasps the penis, taking care not to contaminate the surrounding drape. If penis is uncircumcised, retracts foreskin with nondominant hand to expose the meatus.
16. If the foreskin accidentally falls back over the meatus, or if the nurse drops the penis during cleansing, repeats the procedure.
17. Continuing to hold the penis with the nondominant hand, holds forceps in dominant hand and picks up a cotton ball.
18. Beginning at the meatus, cleanses the glans in a circular motion in ever-widening circles and partially down the shaft of the penis.
19. Repeats with at least one more cotton ball.
20. Discards cotton balls as they are used; does not move them across the open, sterile kit and field.
21. Maintaining sterile technique, places the plastic urine receptacle close enough to the urinary meatus for the end of the catheter to rest inside the container as the urine drains (e.g., places container between patient’s thighs)
22. Using the nondominant hand, holds the penis gently but firmly at a 90° angle to the body, exerting gentle traction.
23. Gently inserts the tip of the prefilled syringe into the urethra and instill the lubricant. (If the kit contains only a single packet of lubricant and if no other kits are available, lubricates 5 to
24. With the dominant hand, holds the catheter
25. Asks the patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.
26. Continues gentle insertion of catheter until urine flows. This is about 7 to
27. If resistance is felt, withdraws the catheter; does not force the catheter.
28. Continues to hold the penis and catheter securely in hand while the urine drains from the bladder.
29. If a urine specimen is to be collected, uses dominant hand to place the specimen container into the flow of urine; caps container using sterile technique.
30. When the flow of urine has ceased and the bladder has been emptied, pinches the catheter and slowly withdraws it from the meatus.
31. Discards catheter.
32. Removes the urine-filled receptacle and sets aside to be emptied when the procedure is finished.
33. Cleanses and dries patient’s penis and perineal area as needed; replaces foreskin over end of penis.
34. Removes gloves; washes hands.
35. Returns patient to a position of comfort.
36. Discards supplies in appropriate receptacle.
Collecting a Clean-Catch Urine Specimen
NOTE: If patient is can do self care, instructs patient in the following steps. If not, performs them for the patient.
30. Assists patient to toilet, commode, or onto bedpan.
31. Opens prepackaged kit, if available, and removes contents.
32. Washes hands and dons clean procedure gloves.
33. Instructs patient to cleanse around the urinary meatus if able; if not able, performs cleansing.
34. Asks patient to spread her legs; washes perineal area with warm water and mild soap.
35. Opens the antiseptic towelette in the prepackaged kit. If there is no kit, pours antiseptic solution over cotton balls.
36. Cleanses perineal area in a front-to-back direction; cleanses over the urinary meatus.
37. Cleans the perineal area at least twice.
38. Uses each towelette area or each cotton ball only once.
39. If penis is uncircumcised, retracts the foreskin back from the end of the penis.
40. Uses towelette from the prepackaged kit or pours antiseptic solution over cotton balls.
41. Grasps the penis gently with one hand; with the other hand, cleanses the meatus in a circular motion from the meatus outward; cleanses for a few inches down the shaft of the penis.
42. Cleanses around the meatus at least twice, using each area of the towelette or each cotton ball only once.
NOTE: Some lab manuals recommend rinsing the antiseptic solution from the meatus to prevent contamination of the specimen with antiseptic.
43. Removes gloves; washes hands; dons a second pair of clean procedure gloves.
44. For the patient using a bedpan, raises the head of the bed to a semi-Fowler’s position.
45. Opens the sterile specimen container; does not touch the inside of the lid or the container.
46. Holding the container near the meatus, instructs the patient to begin voiding.
c. For female patient: Holds the labia apart during this step (or teaches self-care patients to do so).
d. For the male patient unable to assist, holds the penis.
47. Allows a small stream of urine to pass, then places the specimen container into the stream.
48. Does not let the end of the male patient’s penis touch the inside of the container; does not touch the female perineum with the container.
49. Collects approximately 30–60 mL of urine.
50. Removes container from the stream and allows the patient to finish emptying the bladder.
51. For the male patient who is uncircumcised, replaces the foreskin over the glans when the procedure is finished.
52. Carefully replaces the container lid, touching only the outside of the cap and container.
53. Cleanses the outside of the container of urine, if necessary.
54. Labels the container with the correct patient information (in many institutions these are preprinted or bar-coded).
55. Places the container in a facility specific carrier (usually a plastic bag) for transport to the lab.
56. Removes gloves and washes hands. If the specimen has been obtained from a patient on a bedpan, leaves gloves on until the bedpan has been removed, emptied, and stored properly.
57. Assists patient back to bed or removes bedpan.
58. Transports the specimen to the lab in a timely manner.
Inserting an Indwelling Urinary Catheter (Female)
1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.
2. Provides good lighting; takes a procedure lamp to the bedside if necessary.
3. Works on the right side of the bed if right-handed; the left side, if left-handed.
4. Assists to dorsal recumbent position (knees flexed, feet flat on the bed). Instructs patient to relax her thighs and let them rotate externally (if patient is able to cooperate).
Alternatively, uses Sims’ position (side-lying with upper leg flexed at hip.
5. If patient is confused, unable to follow directions, or unable to hold her legs in correct position, obtains help.
6. Drapes patient. If dorsal recumbent position is used, folds blanket in a diamond shape, wraps corners around legs, anchors under feet, and folds upper corner down over perineum. If in Sims’ position, drapes so that rectal area is covered.
7. Dons clean procedure gloves and washes the perineal area with soap and water; dries perineal area.
8. While washing perineum, locates the urinary meatus.
9. Removes and discards gloves.
10. Washes hands.
11. Organizes the work area:
a. Bedside or over-bed table within nurse’s reach.
b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.
c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.
d. Positions the procedure light or has assistant hold a flashlight.
e. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.
12. Applies sterile drape(s) and underpad.
Variation: Waterproof underpad packed as top item in the kit.
f. Removes the underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.
g. Touching only the corners and shiny side, places the drape flat on the bed, shiny side down, and tucks the top edge under the patient’s buttocks.
h. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.
i. Dons sterile gloves (from kit). (Touching only the glove package, removes it from sterile kit before donning gloves).
j. Picks up fenestrated drape; allows it to unfold without touching other objects; places over perineum with the hole over the labia.
Variation: Sterile gloves packed as top item in the kit.
Uses the following steps instead of Steps 12 a-j:
k. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.
l. Grasps the edges of the sterile underpad and folds the entire edge down 2.5 to
m. Asks patient to raise her hips slightly if she is able.
n. Slides the drape under patient’s buttocks without contaminating the gloves.
o. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Creates “cuff” to protect gloves, as in step 12-l.
p. Places fenestrated drape so that hole is over labia.
13. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.
a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)
b. Lays forceps near cotton balls (omits step if using swabs).
c. Opens specimen container if a specimen is to be collected.
d. Removes any unneeded supplies (e.g., specimen container) from the field.
e. Removes plastic covering from catheter.
f. Opens package and expresses sterile lubricant into the kit tray; lubricates the first 1 to
g. Removes plastic cover from catheter. Attaches the saline-filled syringe to the side port of the catheter and inflates the balloon.
h. Deflates balloon and returns catheter to the kit, leaving the syringe connected to the port.
14. Touching only the sterile box or inside of the wrapping, places the sterile catheter kit (tray and box) down onto the sterile field between the patient’s legs.
15. If the drainage bag is preconnected to the catheter itself, leaves the bag on or near the sterile field until after the catheter is inserted.
16. Cleanses the urinary meatus.
a. Places nondominant hand above the labia and with the thumb and forefinger spreads the patient’s labia, pulls up (or anteriorly) at the same time, to expose the urinary meatus.
b. Holds this position throughout the procedure—firm pressure is necessary.
c. If the labia slip back over the urinary meatus, considers it contaminated and repeats cleansing procedure.
d. With dominant hand, picks up a wet cotton ball (or swab), using forceps, and cleanses perineal area, taking care not to contaminate the sterile glove.
e. Uses one stroke for each area.
f. Wipes from front to back..
g. Uses a new cotton ball for each area.
h. Cleanses in this order: outside far labium majus, outside near labium majus, inside far labium, inside near labium, and directly down the center over the urinary meatus.
If there are only 3 cotton balls in the kit, labia majora should be washed with soap and water initially; and in this step, cleanses only the inside far labium majus, inside near labium, and down center directly over the meatus.
17. Discards used cotton balls or swabs as they are used; does not move them across the open, sterile kit and field.
18. With the dominant hand, holds the catheter approximately
19. Asks the woman to bear down as though she is trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.
20. Continues gentle insertion of catheter until urine flows. This is about 2 to
21. If resistance is felt, twists the catheter slightly or applies gentle pressure; does not force the catheter.
22. If the catheter touches the labia or nonsterile linens, or is inadvertently inserted in the vagina, considers it contaminated and inserts a new, sterile catheter.
23. If catheter is inadvertently inserted into the vagina, leaves the contaminated catheter in the vagina while inserting the new one into the meatus.
24. Continues to hold the catheter securely with the dominant hand; after urine flows, stabilizes the catheter’s position in the urethra and uses the nondominant hand to pick up the saline-filled syringe and inflate the catheter balloon.
25. If the patient complains of severe pain upon inflation of the balloon, the catheter is probably in the urethra. Allows the water to drain out of the balloon and repositions the catheter by advancing it
26. Connects the drainage bag to the end of the catheter if it is not already preconnected. Hangs the drainage bag on the side of the bed, below the level of the bladder.
27. Using a tape or a catheter strap, secures the catheter to the thigh.
28. Cleanses patients perineal area as needed, and dries.
29. Removes gloves; washes hands.
30. Returns patient to a position of comfort.
31. Discards supplies in appropriate receptacle.
