Patient Restraint Protocols

Restraints

• Use restraints as a last resort, after less restrictive measures have failed
• Obtain informed consent from the patient or responsible party if the patient cannot provide consent
• Document any refusals, notify the doctor, and the responsible party when restraints are used. Assess their mental function.
• Restraints can be physical or chemical
• Position the patient on their side to prevent aspiration
• Safety Reminder Devices (SRDs) require a doctor's order including type, location, duration of use, and client behaviors prompting their use
• Nurses can apply SRDs in emergencies but must obtain an order within one hour
• Orders for SRD use may need to be rewritten every 24 hours
• While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches
• Monitor the client's circulation, anxiety, and behavior frequently
• Document precipitating events, alternative actions taken, and client and family explanations.
• Restraints should be attached to the movable part of the bed frame
• Check every 15-30 minutes, release for toilet breaks, and perform Range of Motion (ROM) exercises every 2 hours

Distal Restraint Safety

• Check skin and circulation frequently where distal restraints are placed
• If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly

Lifts

• Always lock lifts before use
• Ensure the base of the lift is correctly spread out
• Carefully position the client in the center of the sling
• Seek help if unsure about using a lift and never use it alone

Wheelchairs

• Lock the wheels of the wheelchair when stationary
• Position the wheelchair on the client’s strong side
• Never secure any tubing or lines to the wheelchair or any moveable part

Oxygen Therapy

• Oxygen is an odorless, tasteless, colorless, and non-flammable gas but it supports combustion
• The Flow Meter regulates the oxygen flow rate
• Oxygen is typically ordered in liters per minute (L/min)
• Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min
• Long-term oxygen use requires humidification
• Enforce NO SMOKING signs strictly around oxygen
• Know the location of all fire extinguishers
• Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk
• Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment

Methods of Oxygen Delivery

• Nasal Canula (Bi-prongs):
  • Documented as BNP or BNC
  • Delivers 24-40% concentration
  • Fits into the nares
  • Maximum flow rate of 6 liters
  • Turn oxygen on before placing the canula on the patient
  • Tubing goes over the ears and under the chin
  • Assess and document skin condition behind the ears and in the nares before, during, and after treatment
  • Only use water-soluble lubricants
• Face Mask:
  • Provides greater control over oxygen levels
  • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
  • Humidified oxygen should produce a fine mist
  • Adjust the mask snugly over the nose and chin
  • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission)
• Types of Face Masks:
  • Venturi: Delivers very precise amounts of oxygen
  • Non-rebreather: Delivers up to 100% oxygen
  • Simple: Delivers 40-60% oxygen
• Oxygen Tent:
  • Delivers a fine mist, maintains a constant temperature, and provides high concentration
  • The canopy should cover at least the patient's torso
  • Keep the patient dry to prevent chilling and change linens frequently
  • The internal temperature should be at least 70 degrees
  • Adjust the oxygen flow rate to 10-12 L/min
  • Tuck the tent sides under the mattress if needed
  • Parents might have to get under the tent with a child
• Hyperbaric Chamber:
  • Delivers 100% oxygen at 3 times the atmospheric pressure
  • Facilitates faster tissue regeneration, particularly beneficial for wound healing
• Ambu Bag:
  • Delivers up to 100% oxygen depending on the presence of a reservoir
  • The mask must firmly cover the nose and mouth to create a seal
  • Deliver breaths every 5 seconds
  • Can be attached to an endotracheal tube (ET)

Patient Teaching for Oxygen Therapy

• Explain oxygen application and safety procedures

• Discuss the signs and symptoms of oxygen toxicity:

  • Seen in concentrations over 50% for longer than 24-48 hours
  • Nonproductive cough
  • Substernal chest pain
  • Nasal stuffiness/congestion
  • Nausea/vomiting
  • Fatigue
  • Headache
  • Sore throat
  • Hypoventilation

• Emphasize the importance of oral hygiene

• Encourage fluid intake

• Teach the patient about T C D B (Turn, Cough, Deep, Breath)

  Fire Safety

• RACE:

  • Rescue Patients
  • Alert the alarm
  • Confine the fire
  • Extinguish the fire

• PASS:

  • Pull the pin
  • Aim low
  • Squeeze the trigger
  • Sweep from side to side

Types of Isolation

• Airborne: Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei
  • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19
• Isolation Precautions:
  • Single-patient room
  • room with negative air pressure
  • Room vented to the outside
  • Door to the patient's room remains closed
  • N-95 mask or better
• Droplet: Used for patients with known or suspected illnesses caused by large particle droplets
  • Examples of Illnesses:
    • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis)
    • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis)
    • Serious Respiratory Illnesses:
      • Diphtheria (Pharyngeal)
      • Mycoplasma Pneumonia
      • Pertussis
      • Pneumonic Plague
      • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
    • Serious Viral Illnesses:
      • Adenovirus
      • Influenza
      • Mumps
      • Parvovirus B19
      • Rubella (German Measles)
  • Isolation for Droplet Precaution:
    • Standard PPE
    • Private room or at least 3 feet separation from roommates
    • Limited patient transportation, wear a mask during transport
• Contact: Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment
  • Isolation for Contact Precaution:
    • Gloves and gown required when entering the room
    • Dedicated equipment for the patient
    • Careful hand hygiene

Wound Irrigation

• Sterile procedure
• Promotes wound healing and comfort
• Gentle cleansing technique to prevent further tissue damage
• Clean from the least contaminated to the most contaminated area
• Use a syringe alone or with an IV catheter or needle
• Wash hands before and after the procedure
• Use a collection device to catch irrigation fluid
• Wear appropriate PPE

Tracheostomy Care

• Suctioning:
  • Nasopharyngeal/Tracheal: Sterile
  • Oropharyngeal: Clean
  • Suction only when withdrawing the catheter (coming out)
  • Assess respiratory status before and after suctioning

Indwelling Urinary Catheter

• Sterile procedure
• Follow the same steps as the check-off procedure

Enemas

• Clean procedure
• Types:
  • Fleet
  • Oil retention
  • Soap/Suds (SSE)
  • Tap water (TWE)
• Steps to Perform an Enema:
  • Position the patient in left Sims position
  • Ensure the solution temperature is no higher than 105 degrees
  • Add soap only after the water has entered the rectum
  • Hold the container no higher than 18 inches from the patient's body
  • Typically, no more than 3 enemas are administered without a physician's permission
  • Review the procedure carefully

Tube Feeding

• Follow the same steps as the check-off procedure
• Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding

Hygiene

• Do not use soap on the face unless the patient requests it
• Rinse all soap from the body thoroughly to prevent skin irritation
• Use long strokes when washing, moving towards the heart

Baths

• Tepid: Used to reduce fever
• Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids
• Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown

Vital Signs

• Pain is now considered the 5th vital sign
• Always know the patient's baseline vital signs: weight, height, and temperature. Use the same scale, clothing, and time of day for daily weight measurements

Wound Healing: Phases

• Phase I: Inflammatory Phase:
  • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate
  • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
  • Inflammation: The site is invaded by white blood cells.
• Phase II: Proliferation Phase:
  • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination
  • Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
  • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue
  • Collagen formation increases rapidly between post-op days 5-25
  • Wound dehiscence most frequently occurs during this phase
• Phase IV: Maturation Phase:
  • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger
  • The wound will continue to gain strength but healing can take up to 1 year
  • Internal wounds (Stomach, Colon) regain faster than skin wounds
  • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.
• Primary Intention: Skin edges of the wound are close together, and little tissue is lost
  • Primary intention healing begins in the inflammatory phase
• Secondary Intention: When a wound must granulate during healing, and the edges are not approximate (come together), or when pus is visible
• Tertiary Intention: Delayed primary intention. The provider will leave a contaminated wound open and close it later once the infection is controlled

Wound Terminology

• Purulent: Contains or produces pus
• Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes

PPE (Personal Protective Equipment)

• PPE should be worn for any patient with any suspicion of or known infectious disease.
• Types of PPE:
  • Gown
  • Mask
  • Goggles (or other eye protection)
  • Gloves
• PPE Removal Order:
  • Gloves
  • Gown
  • Goggles
  • Mask
• DON - means to put on
• DOFF - means to take off

Restraints

• Always obtain consent for restraints, ensure the client's mental status allows for informed consent
• Document any refusals, notify the doctor, and the responsible party when restraints are used.
• Assess their mental function.
• Restraints are considered a last resort and alternatives should always be explored first.
• Restraints can be physical or chemical
• When using restraints, position the client on their side to prevent aspiration.
• SRDs require a doctor's order including type, location, duration of use, and client behaviors prompting their use.
• Nurses can apply SRDs in emergencies but must obtain an order within one hour.
• Orders for SRD use may need to be rewritten every 24 hours.
• While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
• Monitor the client's circulation, anxiety, and behavior frequently.
• Document precipitating events, alternative actions taken, and client and family explanations.
• Use quick-release ties and attach to the movable part of the bed frame.
• Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours

Distal Restraint Safety

• Check skin and circulation frequently where distal restraints are placed.
• If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

### Lifts

• Always lock lifts before use
• Ensure the base of the lift is correctly spread out
• Carefully position the client in the center of the sling
• Seek help if unsure about using a lift and never use it alone

### Wheelchairs

• Lock the wheels of the wheelchair when stationary
• Position the wheelchair on the client’s strong side
• Never secure any tubing or lines to the wheelchair or any moveable part

Oxygen Therapy

• Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion
• The Flow Meter regulates the oxygen flow rate
• Oxygen is typically ordered in liters per minute (L/min)
• Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min
• Long-term oxygen use requires humidification
• Enforce NO SMOKING signs strictly around oxygen
• Know the location of all fire extinguishers
• Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk
• Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment

Methods of Oxygen Delivery

Nasal Canula (Bi-prongs):

• Documented as BNP or BNC
• Fits into the nares
• Delivers 24-40% concentration
• Maximum flow rate of 6 liters
• Turn oxygen on before placing the canula on the patient
• Tubing goes over the ears and under the chin
• Assess and document skin condition behind the ears and in the nares before, during, and after treatment
• Only use water-soluble lubricants

Face Mask:

• Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
• Humidified oxygen should produce a fine mist
• Adjust the mask snugly over the nose and chin
• The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission)

Types of Face Masks:

• Venturi: Delivers very precise amounts of oxygen
• Non-rebreather: Delivers up to 100% oxygen
• Simple: Delivers 40-60% oxygen

Oxygen Tent:

• Delivers a fine mist, maintains a constant temperature, and provides high concentration
• The canopy should cover at least the patient's torso
• Keep the patient dry to prevent chilling and change linens frequently
• The internal temperature should be at least 70 degrees
• Adjust the oxygen flow rate to 10-12 L/min
• Tuck the tent sides under the mattress if needed
• Parents might have to get under the tent with a child

Hyperbaric Chamber:

• Delivers 100% oxygen at 3 times the atmospheric pressure
• Facilitates faster tissue regeneration, particularly beneficial for wound healing

Ambu Bag:

• Delivers up to 100% oxygen depending on the presence of a reservoir
• The mask must firmly cover the nose and mouth to create a seal
• Deliver breaths every 5 seconds
• Can be attached to an endotracheal tube (ET)

### Patient Teaching for Oxygen Therapy

• Explain oxygen application and safety procedures
• Discuss the signs and symptoms of oxygen toxicity:
  • Seen in concentrations over 50% for longer than 24-48 hours
  • Nonproductive cough
  • Substernal chest pain
  • Nasal stuffiness/congestion
  • Nausea/vomiting
  • Fatigue
  • Headache
  • Sore throat
  • Hypoventilation
• Emphasize the importance of oral hygiene
• Encourage fluid intake
• Teach the patient about T C D B (Turn, Cough, Deep, Breath)

Fire Safety

• RACE:
  • Rescue Patients
  • Alert the alarm
  • Confine the fire
  • Extinguish the fire
• PASS:
  • Pull the pin
  • Aim low
  • Squeeze the trigger
  • Sweep from side to side

### Types of Isolation

Airborne:

• Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei
• Examples: Measles, Varicella zoster virus (Chickenpox) , TB, COVID-19
• Isolation Precautions:
  • Single-patient room
  • Room with negative air pressure
  • Room vented to the outside
  • Door to the patient's room remains closed
  • Wear N-95 mask or better.

Droplet:

• Used for patients with known or suspected illnesses caused by large particle droplets
• Examples of Illnesses:
  • Invasive Haemophilus Influenzae
  • Invasive Neisseria Meningitidis Disease
  • Serious Respiratory Illnesses: Diphtheria, Mycoplasma Pneumonia, Pertussis, Pneumonic Plague, Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
  • Serious Viral Illnesses: Adenovirus, Influenza, Mumps, Parvovirus B19, Rubella
• Isolation for Droplet Precaution:
  • Standard PPE
  • Private room or at least 3 feet separation from roommates
  • Limited patient transportation, wear a mask during transport

Contact:

• Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment
• Isolation for Contact Precaution:
  • Gloves and gown required when entering the room
  • Dedicated equipment for the patient
  • Careful hand hygiene

### Wound Irrigation

• Sterile procedure
• Promotes wound healing and comfort
• Gentle cleansing technique to prevent further tissue damage
• Clean from the least contaminated to the most contaminated area
• Use a syringe alone or with an IV catheter or needle
• Wash hands before and after the procedure
• Use a collection device to catch irrigation fluid
• Wear appropriate PPE

### Tracheostomy Care

Suctioning:

• Nasopharyngeal/Tracheal: Sterile
• Oropharyngeal: Clean
• Suction only when withdrawing the catheter (coming out)
• Assess respiratory status before and after suctioning

Indwelling Urinary Catheter

• Sterile procedure
• Follow the same steps as the check-off procedure

### Enemas

• Clean procedure
• Types:
  • Fleet
  • Oil retention
  • Soap/Suds (SSE)
  • Tap water (TWE)
• Steps to Perform an Enema:
  • Position the patient in left Sims position
  • Ensure the solution temperature is no higher than 105 degrees
  • Add soap only after the water has entered the rectum
  • Hold the container no higher than 18 inches from the patient's body
  • Typically, no more than 3 enemas are administered without a physician's permission
  • Review the procedure carefully

### Tube Feeding

• Follow the same steps as the check-off procedure
• Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding

Hygiene

• Do not use soap on the face unless the patient requests it
• Rinse all soap from the body thoroughly to prevent skin irritation
• Use long strokes when washing, moving towards the heart

Baths

• Tepid: Used to reduce fever
• Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids
• Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown

### Vital Signs

• Pain is now considered the 5th vital sign
• Always know the patient's baseline vital signs: weight, height, and temperature.
• Use the same scale, clothing, and time of day for daily weight measurements

### Wound Healing: Phases

Phase I: Inflammatory Phase:

• Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
• Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
• Inflammation: The site is invaded by white blood cells.

Phase II: Proliferation Phase:

• New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
• Collagen Formation: Occurs during reconstruction or proliferation phase. The would contracts as new tissue is reconstructed.
• Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue. Collagen formation increases rapidly between post-op days 5-25
• Wound dehiscence most frequently occurs during this phase.

Phase IV: Maturation Phase:

• Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger.
• The wound will continue to gain strength but healing can take up to 1 year.
• Internal wounds (Stomach, Colon) regain faster than skin wounds.
• Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

Wound Terminology

• Purulent: Contains or produces pus.
• Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

PPE (Personal Protective Equipment)

• PPE should be worn for any patient with any suspicion of or known infectious disease.
• Types of PPE:
  • Gown
  • Mask
  • Goggles (or other eye protection)
  • Gloves
• PPE Removal Order:
  • Gloves
  • Gown
  • Goggles
  • Mask
• DON- means to put on
• DOFF - means to take off

Restraints

• Check skin and circulation regularly when restraints are used.
• Obtain consent for restraints, ensuring the client’s mental status allows for informed consent.
• Document refusals, notify the doctor, and the responsible party when restraints are used.
• Assess their mental function.
• Safety reminder devices should be used for the shortest amount of time possible and only after less restrictive measures have failed.
• Seclusion can be requested by the client and is a safe, private area for them to calm down on their own.
• Restraints are considered a last resort and alternatives should always be explored first.
• Restraints can be physical or chemical.
• When using restraints, position the client on their side to prevent aspiration.
• SRDs (Safety Reminder Devices) require a doctor’s order including type, location, duration of use, and client behaviors prompting their use.
• Nurses can apply SRDs in emergencies but must obtain an order within one hour.
• Orders for SRD use may need to be rewritten every 24 hours.
• While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
• Monitor the client’s circulation, anxiety, and behavior frequently.
• Document precipitating events, alternative actions taken, and client and family explanations.
• Use quick-release ties and attach to the movable part of the bed frame.
• Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.

Distal Restraint Safety

• Check skin and circulation frequently where distal restraints are placed.
• If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

Lifts

• Always lock lifts before use.
• Ensure the base of the lift is correctly spread out.
• Carefully position the client in the center of the sling.
• Seek help if unsure about using a lift and never use it alone.

Wheelchairs

• Lock the wheels of the wheelchair when stationary.
• Position the wheelchair on the client’s strong side.
• Never secure any tubing or lines to the wheelchair or any moveable part.

Oxygen therapy

• Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
• The Flow Meter regulates the oxygen flow rate.
• Oxygen is typically ordered in liters per minute (L/min).
• Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
• Long-term oxygen use requires humidification.
• Enforce NO SMOKING signs strictly around oxygen.
• Know the location of all fire extinguishers.
• Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.
• Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment.

Methods of Oxygen Delivery

Nasal Canula (Bi-prongs)

• Documented as BNP or BNC
• Fits into the nares
• Delivers 24-40% concentration
• Maximum flow rate of 6 liters
• Turn oxygen on before placing the canula on the patient
• Tubing goes over the ears and under the chin
• Assess and document skin condition behind the ears and in the nares before, during, and after treatment
• Only use water-soluble lubricants

Face Mask

• Provides greater control over oxygen levels
• Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
• Humidified oxygen should produce a fine mist
• Adjust the mask snugly over the nose and chin
• The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor’s permission)

Types of Face Masks

• Venturi: Delivers very precise amounts of oxygen
• Non-rebreather: Delivers up to 100% oxygen
• Simple: Delivers 40-60% oxygen

Oxygen Tent

• Delivers a fine mist, maintains a constant temperature, and provides high concentration
• The canopy should cover at least the patient’s torso
• Keep the patient dry to prevent chilling and change linens frequently
• The internal temperature should be at least 70 degrees
• Adjust the oxygen flow rate to 10-12 L/min
• Tuck the tent sides under the mattress if needed
• Parents might have to get under the tent with a child

Hyperbaric chamber

• Delivers 100% oxygen at 3 times the atmospheric pressure
• Facilitates faster tissue regeneration, particularly beneficial for wound healing

Ambu Bag

• Delivers up to 100% oxygen depending on the presence of a reservoir
• The mask must firmly cover the nose and mouth to create a seal
• Deliver breaths every 5 seconds
• Can be attached to an endotracheal tube (ET)

Patient Teaching for Oxygen Therapy

• Explain oxygen application and safety procedures
• Discuss the signs and symptoms of oxygen toxicity
  • Seen in concentrations over 50% for longer than 24-48 hours
  • Nonproductive cough
  • Substernal chest pain
  • Nasal stuffiness/congestion
  • Nausea/vomiting
  • Fatigue
  • Headache
  • Sore throat
  • Hypoventilation
• Emphasize the importance of oral hygiene
• Encourage fluid intake
• Teach the patient about T C D B (Turn, Cough, Deep, Breath).

Fire Safety

RACE

• Rescue Patients
• Alert the alarm
• Confine the fire
• Extinguish the fire

PASS

• Pull the pin
• Aim low
• Squeeze the trigger
• Sweep from side to side

Types of Isolation

Airborne: Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei

• Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19

Isolation Precautions

• Single-patient room
• Room with negative air pressure
• Room vented to the outside
• Door to the patient's room remains closed
• N-95 mask or better

Droplet: Used for patients with known or suspected illnesses caused by large particle droplets

Examples of Illnesses

• Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis)
• Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis)
• Serious Respiratory Illnesses
  • Diphtheria (Pharyngeal)
  • Mycoplasma Pneumonia
  • Pertussis
  • Pneumonic Plague
  • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
• Serious Viral Illnesses
  • Adenovirus
  • Influenza
  • Mumps
  • Parvovirus B19
  • Rubella (German Measles)

Isolation for Droplet Precaution

• Standard PPE
• Private room or at least 3 feet separation from roommates
• Limited patient transportation, wear a mask during transport

Contact: Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient’s environment

Isolation for Contact Precaution

• Gloves and gown required when entering the room
• Dedicated equipment for the patient
• Careful hand hygiene

Wound Irrigation

• Sterile procedure
• Promotes wound healing and comfort
• Gentle cleansing technique to prevent further tissue damage
• Clean from the least contaminated to the most contaminated area
• Use a syringe alone or with an IV catheter or needle
• Wash hands before and after the procedure
• Use a collection device to catch irrigation fluid
• Wear appropriate PPE

Tracheostomy Care

Suctioning

• Nasopharyngeal/Tracheal: Sterile
• Oropharyngeal: Clean
• Suction only when withdrawing the catheter (coming out)
• Assess respiratory status before and after suctioning

Indwelling Urinary Catheter

• Sterile procedure
• Follow the same steps as the check-off procedure

Enemas

• Clean procedure

Types

• Fleet
• Oil retention
• Soap/Suds (SSE)
• Tap water (TWE)

Steps to Perform an Enema

• Position the patient in left Sims position
• Ensure the solution temperature is no higher than 105 degrees
• Add soap only after the water has entered the rectum
• Hold the container no higher than 18 inches from the patient’s body
• Typically, no more than 3 enemas are administered without a physician's permission
• Review the procedure carefully

Tube Feeding

• Follow the same steps as the check-off procedure
• Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding

Hygiene

• Do not use soap on the face unless the patient requests it
• Rinse all soap from the body thoroughly to prevent skin irritation
• Use long strokes when washing, moving towards the heart

Baths

• Tepid: Used to reduce fever
• Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids
• Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown

Vital Signs

• Pain is now considered the 5th vital sign
• Always know the patient’s baseline vital signs: weight, height, and temperature.
• Use the same scale, clothing, and time of day for daily weight measurements

Wound Healing: Phases

Phase I: Inflammatory Phase

• Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
• Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
• Inflammation: The site is invaded by white blood cells.

Phase II: Proliferation Phase

• New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
• Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
• Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue.
• Collagen formation increases rapidly between post-op days 5-25.
• Wound dehiscence most frequently occurs during this phase.

Phase IV: Maturation Phase

• Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger.
• The wound will continue to gain strength but healing can take up to 1 year.
• Internal wounds (Stomach, Colon) regain faster than skin wounds.
• Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

Wound Terminology

• Purulent: Contains or produces pus.
• Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

PPE (Personal Protective Equipment)

• PPE should be worn for any patient with any suspicion of or known infectious disease.

Types of PPE

• Gown
• Mask
• Goggles (or other eye protection)
• Gloves

PPE Removal Order

• Gloves

• Gown

• Goggles

• Mask

• DON- means to put on

• DOFF- means to take off

Restraints

• Use restraints only after less restrictive measures have failed.
• Obtain consent for restraints, ensure the client's mental status allows for informed consent and document any refusals.
• Restraints can be physical or chemical.
• Physical restraints require a doctor's order including type, location, duration of use, and client behaviors prompting their use.
• Nurses can apply restraints in emergencies but must obtain an order within one hour.
• Orders for restraint use may need to be rewritten every 24 hours.
• Assess skin every two hours for pressure points, tears, or scratches.
• Monitor the client's circulation, anxiety, and behavior frequently.
• Document precipitating events, alternative actions taken, and client and family explanations.
• Use quick-release ties and attach to the movable part of the bed frame.
• Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.
• Position the client on their side to prevent aspiration.

Distal Restraint Safety

• Check skin and circulation frequently where distal restraints are placed.
• If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

Lifts

• Always lock lifts before use.
• Ensure the base of the lift is correctly spread out.
• Carefully position the client in the center of the sling.
• Seek help if unsure about using a lift and never use it alone.

Wheelchairs

• Lock the wheels of the wheelchair when stationary.
• Position the wheelchair on the client's strong side.
• Never secure any tubing or lines to the wheelchair or any moveable part.

Oxygen Therapy

• Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
• The Flow Meter regulates the oxygen flow rate.
• Oxygen is typically ordered in liters per minute (L/min).
• Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
• Long-term oxygen use requires humidification.
• Enforce NO SMOKING signs strictly around oxygen.
• Know the location of all fire extinguishers.
• Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.
• Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment.

Methods of Oxygen Delivery

Nasal Canula (Bi-prongs)

• Documented as BNP or BNC.
• Fits into the nares.
• Delivers 24-40% concentration.
• Maximum flow rate of 6 liters.
• Turn oxygen on before placing the canula on the patient.
• Tubing goes over the ears and under the chin.
• Assess and document skin condition behind the ears and in the nares before, during, and after treatment.
• Only use water-soluble lubricants.

Face Mask

• Provides greater control over oxygen levels.
• Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L.
• Humidified oxygen should produce a fine mist.
• Adjust the mask snugly over the nose and chin.
• The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission).

Types of Face Masks:

• Venturi: Delivers very precise amounts of oxygen.
• Non-rebreather: Delivers up to 100% oxygen.
• Simple: Delivers 40-60% oxygen.

Oxygen Tent

• Delivers a fine mist, maintains a constant temperature, and provides high concentration.
• The canopy should cover at least the patient's torso.
• Keep the patient dry to prevent chilling and change linens frequently.
• The internal temperature should be at least 70 degrees.
• Adjust the oxygen flow rate to 10-12 L/min
• Tuck the tent sides under the mattress if needed.
• Parents might have to get under the tent with a child.

Hyperbaric Chamber

• Delivers 100% oxygen at 3 times the atmospheric pressure.
• Facilitates faster tissue regeneration, particularly beneficial for wound healing.

Ambu Bag

• Delivers up to 100% oxygen depending on the presence of a reservoir.
• The mask must firmly cover the nose and mouth to create a seal.
• Deliver breaths every 5 seconds.
• Can be attached to an endotracheal tube (ET).

Patient Teaching for Oxygen Therapy

• Explain oxygen application and safety procedures.
• Discuss the signs and symptoms of oxygen toxicity:
  • Seen in concentrations over 50% for longer than 24-48 hours.
  • Nonproductive cough.
  • Substernal chest pain.
  • Nasal stuffiness/congestion.
  • Nausea/vomiting.
  • Fatigue.
  • Headache.
  • Sore throat.
  • Hypoventilation.
• Emphasize the importance of oral hygiene.
• Encourage fluid intake.
• Teach the patient about T C D B (Turn, Cough, Deep, Breath).

Fire Safety

RACE:

• Rescue Patients
• Alert the alarm
• Confine the fire
• Extinguish the fire

PASS:

• Pull the pin
• Aim low
• Squeeze the trigger
• Sweep from side to side

Types of Isolation

Airborne:

• Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei.
• Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19.

Isolation Precautions:

• Single-patient room.
• Room with negative air pressure.
• Room vented to the outside.
• Door to the patient's room remains closed.
• N-95 mask or better.

Droplet:

• Used for patients with known or suspected illnesses caused by large particle droplets.

Examples of Illnesses:

• Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis).
• Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis).
• Serious Respiratory Illnesses
  • Diphtheria (Pharyngeal).
  • Mycoplasma Pneumonia.
  • Pertussis.
  • Pneumonic Plague.
  • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children.
• Serious Viral Illnesses
  • Adenovirus.
  • Influenza.
  • Mumps.
  • Parvovirus B19.
  • Rubella (German Measles).

Isolation for Droplet Precaution:

• Standard PPE.
• Private room or at least 3 feet separation from roommates.
• Limited patient transportation, wear a mask during transport.

Contact:

• Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment.

Isolation for Contact Precaution:

• Gloves and gown required when entering the room.
• Dedicated equipment for the patient.
• Careful hand hygiene.

Wound Irrigation

• Sterile procedure.
• Promotes wound healing and comfort.
• Gentle cleansing technique to prevent further tissue damage.
• Clean from the least contaminated to the most contaminated area.
• Use a syringe alone or with an IV catheter or needle.
• Wash hands before and after the procedure.
• Use a collection device to catch irrigation fluid.
• Wear appropriate PPE.

Tracheostomy Care

Suctioning:

• Nasopharyngeal/Tracheal: Sterile.
• Oropharyngeal: Clean.
• Suction only when withdrawing the catheter (coming out).
• Assess respiratory status before and after suctioning.

Indwelling Urinary Catheter

• Sterile procedure.
• Follow the same steps as the check-off procedure.

Enemas

• Clean procedure.
• Types:
  • Fleet.
  • Oil retention.
  • Soap/Suds (SSE).
  • Tap water (TWE).

Steps to Perform an Enema:

• Position the patient in left Sims position.
• Ensure the solution temperature is no higher than 105 degrees.
• Add soap only after the water has entered the rectum.
• Hold the container no higher than 18 inches from the patient's body.
• Typically, no more than 3 enemas are administered without a physician's permission.
• Review the procedure carefully.

Tube Feeding

• Follow the same steps as the check-off procedure.
• Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding.

Hygiene

• Do not use soap on the face unless the patient requests it.
• Rinse all soap from the body thoroughly to prevent skin irritation.
• Use long strokes when washing, moving towards the heart.

Baths

• Tepid: Used to reduce fever.
• Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids.
• Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown.

Vital Signs

• Pain is now considered the 5th vital sign.
• Always know the patient's baseline vital signs: weight, height, and temperature.
• Use the same scale, clothing, and time of day for daily weight measurements.

Wound Healing: Phases

Phase I: Inflammatory Phase:

• Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
• Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
• Inflammation: The site is invaded by white blood cells.

Phase II: Proliferation Phase:

• New cells and capillaries fill in the wound from the underlying tissue to the skin surface.
• This process seals the wound and protects from contamination.

Collagen Formation:

• Occurs during reconstruction or proliferation phase.
• The would contracts as new tissue is reconstructed.
• Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue.
• Collagen formation increases rapidly between post-op days 5-25.
• Wound dehiscence most frequently occurs during this phase.

Phase IV: Maturation Phase:

• Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger.
• The wound will continue to gain strength but healing can take up to 1 year.
• Internal wounds (Stomach, Colon) regain faster than skin wounds.
• Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

Wound Terminology

• Purulent: Contains or produces pus.
• Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

PPE (Personal Protective Equipment)

• PPE should be worn for any patient with any suspicion of or known infectious disease.

Types of PPE:

• Gown
• Mask
• Goggles (or other eye protection)
• Gloves

PPE Removal Order:

• Gloves

• Gown

• Goggles

• Mask

• DON- means to put on.

• DOFF - means to take off.

Restraints

• Check skin and circulation regularly when restraints are used.
• Always obtain consent for restraints, ensure the client's mental status allows for informed consent.
• Document any refusals, notify the doctor, and the responsible party when restraints are used. Assess their mental function.
• Safety reminder devices should be used for the shortest amount of time possible and only after less restrictive measures have failed.
• Seclusion can be requested by the client and is a safe, private area for them to calm down on their own.
• Restraints are considered a last resort and alternatives should always be explored first.
• Restraints can be physical or chemical.
• When using restraints, position the client on their side to prevent aspiration.
• SRDs require a doctor's order including type, location, duration of use, and client behaviors prompting their use.
• Nurses can apply SRDs in emergencies but must obtain an order within one hour.
• Orders for SRD use may need to be rewritten every 24 hours.
• While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
• Monitor the client's circulation, anxiety, and behavior frequently.
• Document precipitating events, alternative actions taken, and client and family explanations.
• Use quick-release ties and attach to the movable part of the bed frame.
• Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.

Distal Restraint Safety

• Check skin and circulation frequently where distal restraints are placed.
• If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

Lifts

• Always lock lifts before use.
• Ensure the base of the lift is correctly spread out.
• Carefully position the client in the center of the sling.
• Seek help if unsure about using a lift and never use it alone.

Wheelchairs

• Lock the wheels of the wheelchair when stationary.
• Position the wheelchair on the client's strong side.
• Never secure any tubing or lines to the wheelchair or any moveable part.

Oxygen Therapy

• Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
• The Flow Meter regulates the oxygen flow rate.
• Oxygen is typically ordered in liters per minute (L/min).
• Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
• Long-term oxygen use requires humidification.
• Enforce NO SMOKING signs strictly around oxygen.
• Know the location of all fire extinguishers.
• Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.

Examples of combustible materials to avoid:

• Grease
• Oil
• Vaseline
• Alcohol
• Ether
• Any ungrounded equipment

Methods Of Oxygen Delivery

Nasal Canula (Bi-prongs):

• Documented as BNP or BNC.
• Fits into the nares.
• Delivers 24-40% concentration.
• Maximum flow rate of 6 liters.
• Turn oxygen on before placing the canula on the patient.
• Tubing goes over the ears and under the chin.
• Assess and document skin condition behind the ears and in the nares before, during, and after treatment.
• Only use water-soluble lubricants.

Face Mask

• Provides greater control over oxygen levels.
• Concentration of 60-100% oxygen (required flow rate depends on the L/min). 6-10 L.
• Humidified oxygen should produce a fine mist.
• Adjust the mask snugly over the nose and chin.
• The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission).

Types of Face Masks:

• Venturi: Delivers very precise amounts of oxygen.
• Non-rebreather: Delivers up to 100% oxygen.
• Simple: Delivers 40-60% oxygen.

Oxygen Tent

• Delivers a fine mist, maintains a constant temperature, and provides high concentration.
• The canopy should cover at least the patient's torso.
• Keep the patient dry to prevent chilling and change linens frequently.
• The internal temperature should be at least 70 degrees.
• Adjust the oxygen flow rate to 10-12 L/min.
• Tuck the tent sides under the mattress if needed.
• Parents might have to get under the tent with a child.

Hyperbaric Chamber

• Delivers 100% oxygen at 3 times the atmospheric pressure.
• Facilitates faster tissue regeneration, particularly beneficial for wound healing.

Ambu Bag

• Delivers up to 100% oxygen depending on the presence of a reservoir.
• The mask must firmly cover the nose and mouth to create a seal.
• Deliver breaths every 5 seconds.
• Can be attached to an endotracheal tube (ET).

Patient Teaching for Oxygen Therapy

• Explain oxygen application and safety procedures.
• Discuss the signs and symptoms of oxygen toxicity:
  • Seen in concentrations over 50% for longer than 24-48 hours.
  • Nonproductive cough.
  • Substernal chest pain.
  • Nasal stuffiness/congestion.
  • Nausea/vomiting.
  • Fatigue.
  • Headache.
  • Sore throat.
  • Hypoventilation.
• Emphasize the importance of oral hygiene.
• Encourage fluid intake.
• Teach the patient about T C D B (Turn, Cough, Deep, Breath).

Fire Safety

RACE:

• Rescue Patients
• Alert the alarm
• Confine the fire
• Extinguish the fire

PASS:

• Pull the pin
• Aim low
• Squeeze the trigger
• Sweep from side to side

Types of Isolation

Airborne:

• Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei.
• Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19.

Isolation Precautions:

• Single-patient room.
• Room with negative air pressure.
• Room vented to the outside.
• Door to the patient's room remains closed.
• N-95 mask or better.

Droplet:

• Used for patients with known or suspected illnesses caused by large particle droplets.

Examples of Illnesses:

• Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis)
• Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis)
• Serious Respiratory Illnesses:
  • Diphtheria (Pharyngeal)
  • Mycoplasma Pneumonia
  • Pertussis
  • Pneumonic Plague
  • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children
• Serious Viral Illnesses:
  • Adenovirus
  • Influenza
  • Mumps
  • Parvovirus B19
  • Rubella (German Measles)

Isolation for Droplet Precaution:

• Standard PPE.
• Private room or at least 3 feet separation from roommates.
• Limited patient transportation, wear a mask during transport.

Contact:

• Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment.

Isolation for Contact Precaution:

• Gloves and gown required when entering the room.
• Dedicated equipment for the patient.
• Careful hand hygiene.

Wound Irrigation

• Sterile procedure.
• Promotes wound healing and comfort.
• Gentle cleansing technique to prevent further tissue damage.
• Clean from the least contaminated to the most contaminated area.
• Use a syringe alone or with an IV catheter or needle.
• Wash hands before and after the procedure.
• Use a collection device to catch irrigation fluid.
• Wear appropriate PPE.

Tracheostomy Care

Suctioning:

• Nasopharyngeal/Tracheal: Sterile.
• Oropharyngeal: Clean.
• Suction only when withdrawing the catheter (coming out).
• Assess respiratory status before and after suctioning.

Indwelling Urinary Catheter

• Sterile procedure.
• Follow the same steps as the check-off procedure.

Enemas

• Clean procedure.

Types:

• Fleet
• Oil retention
• Soap/Suds (SSE)
• Tap Water (TWE)

Steps to Perform an Enema:

• Position the patient in left Sims position.
• Ensure the solution temperature is no higher than 105 degrees.
• Add soap only after the water has entered the rectum.
• Hold the container no higher than 18 inches from the patient's body.
• Typically, no more than 3 enemas are administered without a physician's permission.
• Review the procedure carefully.

Tube Feeding

• Follow the same steps as the check-off procedure.
• Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding.

Hygiene

• Do not use soap on the face unless the patient requests it.
• Rinse all soap from the body thoroughly to prevent skin irritation.
• Use long strokes when washing, moving towards the heart.

Baths

• Tepid: Used to reduce fever.
• Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids.
• Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown.

Vital Signs

• Pain is now considered the 5th vital sign.
• Always know the patient's baseline vital signs: weight, height, and temperature.
• Use the same scale, clothing, and time of day for daily weight measurements.

Wound Healing: Phases

Phase I: Inflammatory Phase:

• Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
• Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
• Inflammation: The site is invaded by white blood cells.

Phase II: Proliferation Phase:

• New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
• Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
• Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue. Collagen formation increases rapidly between post-op days 5-25. Wound dehiscence most frequently occurs during this phase.

Phase IV: Maturation Phase:

• Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger. The wound will continue to gain strength but healing can take up to 1 year. Internal wounds (Stomach, Colon) regain faster than skin wounds.
• Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.

Wound Terminology

• Purulent: Contains or produces pus.
• Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

PPE (Personal Protective Equipment)

• PPE should be worn for any patient with any suspicion of or known infectious disease.

Types of PPE:

• Gown
• Mask
• Goggles (or other eye protection)
• Gloves

PPE Removal Order:

• Gloves

• Gown

• Goggles

• Mask

• DON - means to put on

• DOFF - means to take off

Restraints

• Check skin and circulation regularly when restraints are in use.
• Always obtain informed consent for restraints.
• Document refusals, notify the doctor, and the responsible party.
• Safety reminder devices (SRDs) should be used for the shortest amount of time possible and only after less restrictive measures have failed.
• Seclusion can be requested by the client and is a safe, private area for them to calm down.
• Restraints can be physical or chemical.
• When using restraints, position the client on their side to prevent aspiration.
• SRDs require a doctor's order including type, location, duration of use, and the reason for use.
• Nurses can apply SRDs in emergencies but must obtain an order within one hour.
• Orders for SRD use may need to be rewritten every 24 hours.
• While the client is in restraints, assess skin every two hours for pressure points, tears, or scratches.
• Monitor the client's circulation, anxiety, and behavior frequently.
• Document precipitating events, alternative actions taken, and client and family explanations.
• Use quick-release ties and attach to the movable part of the bed frame.
• Check every 15-30 minutes, release to the toilet, and perform ROM exercises every 2 hours.

Distal Restraint Safety

• Check skin and circulation frequently where distal restraints are placed.
• If a client refuses restraints, assess their mental function, notify their doctor and responsible party, and document the refusal thoroughly.

Lifts

• Always lock lifts before use.
• Ensure the base of the lift is correctly spread out.
• Carefully position the client in the center of the sling.
• Seek help if unsure about using a lift and never use it alone.

Wheelchairs

• Lock the wheels of the wheelchair when stationary.
• Position the wheelchair on the client's strong side.
• Never secure any tubing or lines to the wheelchair or any movable part.

Oxygen Therapy

• Oxygen is an odorless, tasteless, colorless, and non-flammable gas, but it supports combustion.
• The Flow Meter regulates the oxygen flow rate.
• Oxygen is typically ordered in liters per minute (L/min).
• Chronic respiratory illnesses require lower oxygen settings, generally no more than 1-2 L/min.
• Long-term oxygen use requires humidification.
• Enforce NO SMOKING signs strictly around oxygen.
• Know the location of all fire extinguishers.
• Only use water-soluble lubricants for oxygen equipment; petroleum-based lubricants can cause a combustion risk.
• Examples of combustible materials to avoid: grease, oil, Vaseline, alcohol, ether, or any ungrounded equipment.

Methods of Oxygen Delivery

• Nasal Canula (Bi-prongs):
  • Documented as BNP or BNC.
  • Fits into the nares.
  • Delivers 24-40% concentration.
  • Maximum flow rate of 6 liters.
  • Turn oxygen on before placing the canula on the patient.
  • Tubing goes over the ears and under the chin.
  • Assess and document skin condition behind the ears and in the nares before, during, and after treatment.
  • Only use water-soluble lubricants.
• Face Mask:
  • Provides greater control over oxygen levels.
  • Concentration of 60-100% oxygen (required flow rate depends on the L/min) 6-10 L
  • Humidified oxygen should produce a fine mist.
  • Adjust the mask snugly over the nose and chin.
  • The reservoir should never fully collapse (increase oxygen flow if it does, but only with a doctor's permission).
  • Types of Face Masks:
    • Venturi: Delivers very precise amounts of oxygen.
    • Non-rebreather: Delivers up to 100% oxygen.
    • Simple: Delivers 40-60% oxygen.
• Oxygen Tent:
  • Delivers a fine mist, maintains a constant temperature, and provides high concentration.
  • The canopy should cover at least the patient's torso.
  • Keep the patient dry to prevent chilling and change linens frequently.
  • The internal temperature should be at least 70 degrees.
  • Adjust the oxygen flow rate to 10-12 L/min.
  • Tuck the tent sides under the mattress if needed.
  • Parents might have to get under the tent with a child.
• Hyperbaric Chamber:
  • Delivers 100% oxygen at 3 times the atmospheric pressure.
  • Facilitates faster tissue regeneration, particularly beneficial for wound healing.
• Ambu Bag:
  • Delivers up to 100% oxygen depending on the presence of a reservoir.
  • The mask must firmly cover the nose and mouth to create a seal.
  • Deliver breaths every 5 seconds.
  • Can be attached to an endotracheal tube (ET).

Patient Teaching for Oxygen Therapy

• Explain oxygen application and safety procedures.
• Discuss the signs and symptoms of oxygen toxicity:
  • Seen in concentrations over 50% for longer than 24-48 hours.
  • Nonproductive cough.
  • Substernal chest pain.
  • Nasal stuffiness/congestion.
  • Nausea/vomiting.
  • Fatigue.
  • Headache.
  • Sore throat.
  • Hypoventilation.
• Emphasize the importance of oral hygiene.
• Encourage fluid intake.
• Teach the patient about T C D B (Turn, Cough, Deep, Breath).

Fire Safety

• RACE:
  • Rescue Patients
  • Alert the alarm
  • Confine the fire
  • Extinguish the fire
• PASS:
  • Pull the pin
  • Aim low
  • Squeeze the trigger
  • Sweep from side to side

Types of Isolation

• Airborne: Used for patients with confirmed or suspected serious illnesses transmitted by airborne droplet nuclei.
  • Examples: Measles, Varicella zoster virus (Chickenpox), TB, COVID-19.
  • Isolation Precautions:
    • Single-patient room.
    • Room with negative air pressure.
    • Room vented to the outside.
    • Door to the patient's room remains closed.
    • N-95 mask or better.
• Droplet: Used for patients with known or suspected illnesses caused by large particle droplets.
  • Examples of Illnesses:
    • Invasive Haemophilus Influenzae (meningitis, pneumonia, epiglottis, & sepsis).
    • Invasive Neisseria Meningitidis Disease (meningitis, pneumonia, & sepsis).
    • Serious Respiratory Illnesses:
      • Diphtheria (Pharyngeal).
      • Mycoplasma Pneumonia.
      • Pertussis.
      • Pneumonic Plague.
      • Streptococcal pharyngitis, pneumonia, & scarlet fever in infants and young children.
    • Serious Viral Illnesses:
      • Adenovirus.
      • Influenza.
      • Mumps.
      • Parvovirus B19.
      • Rubella (German Measles).
  • Isolation for Droplet Precaution:
    • Standard PPE.
    • Private room or at least 3 feet separation from roommates.
    • Limited patient transportation, wear a mask during transport.
• Contact: Used for serious illnesses easily transmitted by direct patient contact or contact with objects in the patient's environment.
  • Isolation for Contact Precaution:
    • Gloves and gown required when entering the room.
    • Dedicated equipment for the patient.
    • Careful hand hygiene.

Wound Irrigation

• Sterile procedure.
• Promotes wound healing and comfort.
• Gentle cleansing technique to prevent further tissue damage.
• Clean from the least contaminated to the most contaminated area.
• Use a syringe alone or with an IV catheter or needle.
• Wash hands before and after the procedure.
• Use a collection device to catch irrigation fluid.
• Wear appropriate PPE.

Tracheostomy Care

• Suctioning:
  • Nasopharyngeal/Tracheal: Sterile
  • Oropharyngeal: Clean
  • Suction only when withdrawing the catheter (coming out).
  • Assess respiratory status before and after suctioning.

Indwelling Urinary Catheter

• Sterile procedure.
• Follow the same steps as the check-off procedure.

Enemas

• Clean procedure.
• Types:
  • Fleet.
  • Oil retention.
  • Soap/Suds (SSE).
  • Tap water (TWE).
• Steps to Perform an Enema:
  • Position the patient in left Sims position.
  • Ensure the solution temperature is no higher than 105 degrees.
  • Add soap only after the water has entered the rectum.
  • Hold the container no higher than 18 inches from the patient's body.
  • Typically, no more than 3 enemas are administered without a physician's permission.
  • Review the procedure carefully.

Tube Feeding

• Follow the same steps as the check-off procedure.
• Remember to check tube placement every time the patient is fed if on intermittent feeding, and every shift if on continuous feeding.

Hygiene

• Do not use soap on the face unless the patient requests it.
• Rinse all soap from the body thoroughly to prevent skin irritation.
• Use long strokes when washing, moving towards the heart.

Baths

• Tepid: Used to reduce fever.
• Sitz: Used for comfort after childbirth, rectal surgery, or hemorrhoids.
• Medicated: Used to moisturize and treat dry skin; monitor for skin breakdown.

Vital Signs

• Pain is now considered the 5th vital sign.
• Always know the patient's baseline vital signs: weight, height, and temperature.
• Use the same scale, clothing, and time of day for daily weight measurements.

Wound Healing: Phases

• Phase I: Inflammatory Phase:
  • Hemostasis: Immediately after injury, the blood vessels constrict and coagulate.
  • Vasodilation: Blood vessels enlarge, increasing blood flow to the area.
  • Inflammation: The site is invaded by white blood cells.
• Phase II: Proliferation Phase:
  • New cells and capillaries fill in the wound from the underlying tissue to the skin surface. This process seals the wound and protects from contamination.
  • Collagen Formation: Occurs during reconstruction or proliferation phase. The wound contracts as new tissue is reconstructed.
  • Myofibroblasts: Produce collagen (glue-like substance) and adds strength to the wound and tissue. Collagen formation increases rapidly between post-op days 5-25. Wound dehiscence most frequently occurs during this phase.
• Phase IV: Maturation Phase:
  • Fibroblasts exit the wound, collagen forms, and tissue and skin become stronger. The wound will continue to gain strength but healing can take up to 1 year. Internal wounds (Stomach, Colon) regain faster than skin wounds.
  • Keloid: Occasionally, an overgrowth of collagen at the site of the wound forms. African Americans, dark-skinned people of all races, and young women are at the highest risk for developing keloids.
• Primary Intention: Skin edges of the wound are close together, and little tissue is lost. Primary intention healing begins in the inflammatory phase.
• Secondary Intention: When a wound must granulate during healing, and the edges are not approximate (come together), or when pus is visible.
• Tertiary Intention: Delayed primary intention. The provider will leave a contaminated wound open and close it later once the infection is controlled.

Wound Terminology

• Purulent: Contains or produces pus.
• Exudate: Fluid, cells, or other substances that have slowly exuded or discharged from cells or blood through small pores or breaks in cell membranes.

PPE (Personal Protective Equipment)

• PPE should be worn for any patient with any suspicion of or known infectious disease.
• Types of PPE:
  • Gown.
  • Mask.
  • Goggles (or other eye protection).
  • Gloves.
• PPE Removal Order:
  • Gloves.
  • Gown.
  • Goggles.
  • Mask.
• DON- means to put on.
• DOFF - means to take off.