Fundamentals of Nursing Practicum PDF

Faculty of Nursing Fundamentals of Nursing Practicum Adopted By Mrs. Fedaa Ayasreh Hand Hygiene Using Soap and Water Adopted by Mrs. Fedaa Ayasreh 2021 Handwashing Han...

Faculty of Nursing Fundamentals of Nursing Practicum Adopted By Mrs. Fedaa Ayasreh Hand Hygiene Using Soap and Water Adopted by Mrs. Fedaa Ayasreh 2021 Handwashing Hand washing is considered as the nest method to decontaminate hands and to prevent transmission of infectious diseases. Equipment: Anti-microbial or non-antimicrobial soap. Paper towels. Expected outcome: The hands will be free of visible soiling and transient microorganisms will be eliminated.  Steps of Handwashing Gather the necessary supplies. Stand in front of the sink. Do not allow your clothing to touch the sink during the washing procedure. The sink is considered contaminated. Clothing may carry organisms from place to place. Remove jewelry, if possible, and secure in a safe place. A plain wedding band may remain in place. Removal of jewelry facilitates proper cleansing. Microorganisms may accumulate in settings of jewelry. If jewelry was worn during care, it should be left on during handwashing.  Steps of Handwashing Turn on water and adjust force. Regulate the temperature until the water is warm. Water splashed from the contaminated sink will contaminate clothing. Warm water is more comfortable. Wet the hands and wrist area. Keep hands lower than elbows to allow water to flow toward fingertips. Water should flow from the cleaner area toward the more contaminated area.  Steps of Handwashing Use about 1 teaspoon of liquid soap from dispenser or rinse bar of soap and lather thoroughly. Cover all areas of hands with the soap product. Rinse soap bar again and return to soap rack. With firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers (Figure 5), and the knuckles, wrists, and forearms. Wash at least 1 inch above area of contamination. If hands are not visibly soiled, wash to 1 inch above the wrists.  Steps of Handwashing Continue this friction motion for at least 15 seconds. Use fingernails of the opposite hand or a clean orangewood stick to clean under fingernails. Rinse thoroughly with water flowing toward fingertips. Pat hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Use another clean towel to turn off the faucet. Discard towel immediately without touching other clean hand.  Using Personal Protective Equipment Adopted by Dr. Ibrahim Ayasreh RN, PhD 2021 Ibrahim Ayasreh RN, PhD, 2021 Personal Protective Equipment Personal protective equipment refers to specialized clothing or equipment worn by an employee for protection against infectious materials. This equipment includes: Clean (nonsterile) and sterile gloves. Impervious gowns/aprons. Disposable face mask. Face shields. Protective eyewear/goggles.  Ibrahim Ayasreh RN, PhD, 2021 Personal Protective Equipment Ibrahim Ayasreh RN, PhD, 2021 Using Personal Protective Equipment Perform hand hygiene.. Put on gown, mask, protective eyewear, and gloves based on the type of exposure anticipated and category of isolation precautions.  Ibrahim Ayasreh RN, PhD, 2021 Using Personal Protective Equipment Apply a clean gown. - Pick up a clean gown, and allow it to unfold in front of you without allowing it to touch any area soiled with body substances. - Slide the arms and the hands through the sleeves. - Fasten the ties at the neck to keep the gown in place. - Overlap the gown at the back as much as possible, and fasten the waist ties or belt. https://www.youtube.com/watch?v=y0W7VtrD07U Ibrahim Ayasreh RN, PhD, 2021 Using Personal Protective Equipment Apply the face mask. - Locate the top edge of the mask. The mask usually has a narrow metal strip along the edge. - Hold the mask by the top two strings or loops. - Place the upper edge of the mask over the bridge of the nose, and tie the upper ties at the back of the head or secure the loops around the ears. - If glasses are worn, fit the upper edge of the mask under the glasses.. - Secure the lower edge of the mask under the chin, and tie the lower ties at the nape of the neck.  Ibrahim Ayasreh RN, PhD, 2021 Using Personal Protective Equipment Apply the face mask. - If the mask has a metal strip, adjust this firmly over the bridge of the nose. - Wear the mask only once, and do not wear any mask longer than the manufacturer recommends or once it becomes wet. - Do not leave a used face mask hanging around the neck. - The Practice Guidelines provide further instructions on applying a face mask. https://www.youtube.com/watch?v=y0W7VtrD07U Ibrahim Ayasreh RN, PhD, 2021 Using Personal Protective Equipment Apply protective eyewear if it is not combined with the face mask. Apply clean gloves. - No special technique is required. - If wearing a gown, pull the gloves up to cover the cuffs of the gown. - If not wearing a gown, pull the gloves up to cover the wrists. https://www.youtube.com/watch?v=vTNuf8Tw9Vg https://www.youtube.com/watch?v=3I_kKVNrEMo  Ibrahim Ayasreh RN, PhD, 2021 Removal of Personal Protective Equipment To remove soiled PPE, remove the gloves first since they are the most soiled. - If wearing a gown that is tied at the waist in front, undo the ties before removing gloves. - Remove the first glove by grasping it on its palmar surface, taking care to touch only glove to glove. - Pull the first glove completely off by inverting or rolling the glove inside out. - Continue to hold the inverted removed glove by the fingers of the remaining gloved hand. Place the first two fingers of the bare hand inside the cuff of the second glove. Rationale: Touching the outside of the second soiled glove with the bare hand is avoided. Ibrahim Ayasreh RN, PhD, 2021 Removal of Personal Protective Equipment - Pull the second glove off to the fingers by turning it inside out. This pulls the first glove inside the second glove. - Using the bare hand, continue to remove the gloves, which are now inside out, and dispose of them in the refuse container. Perform hand hygiene. Remove protective eyewear and dispose of properly or place in the appropriate receptacle for cleaning. Remove the gown when preparing to leave the room https://www.youtube.com/watch?v=xTYioOo__6U Putting on Sterile Gloves and Removing Soiled Gloves Adopted by Mrs. Fedaa Ayasreh 2021 Sterile Gloves  Ibrahim Ayasreh RN, PhD, 2021 Putting Sterile Gloves Perform hand hygiene. Hand hygiene and PPE prevent the spread of microorganisms. Check that the sterile glove package is dry and unopened. Also, note expiration date, making sure that the date is still valid. Moisture contaminates a sterile package. Expiration date indicates period that package remains sterile. Ibrahim Ayasreh RN, PhD, 2021 Putting Sterile Gloves Place sterile glove package on clean, dry surface at or above your waist. Moisture could contaminate the sterile gloves. Any sterile object held below the waist is considered contaminated. Open the outside wrapper by carefully peeling the top layer back. Remove inner package, handling only the outside of it. This maintains sterility of gloves in inner packet.  Putting Sterile Gloves Carefully open the inner package. Fold open the top flap, then the bottom and sides. Take care not to touch the inner surface of the package or the gloves. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for dominant hand, touching only the exposed inside of the glove. Unsterile hand touches only inside of glove. Outside remains sterile. Putting Sterile Gloves Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. Be careful it does not touch any unsterile object. Carefully insert dominant hand palm up into glove and pull glove on. Leave the cuff folded until the opposite hand is gloved.  Ibrahim Ayasreh RN, PhD, 2021 Putting Sterile Gloves Slide the fingers of one hand under the cuff of the other and fully extend the cuff down the arm, touching only the sterile outside of the glove. Repeat for the remaining hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.  Removing Soiled Gloves Use dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove it by pulling it off, inverting it as it is pulled, keeping the contaminated area on the inside. Hold the removed glove in the remaining gloved hand. Slide fingers of ungloved hand between the remaining glove and the wrist. Take care to avoid touching the outside surface of the glove. Remove it by pulling it off, inverting it as it is pulled, keeping the contaminated area on the inside, and securing the first glove inside the second.  Vital Signs Adopted by Dr. Ibrahim Ayasreh 2021 Vital Signs Vital signs are a person s temperature, pulse, respiration, and blood pressure, abbreviated as T, P, R, and BP. Pain, often called the fifth vital sign. The health status of an individual is reflected in these indicators of body function. A change in vital signs may indicate a change in health. Vital signs are assessed and compared with accepted normal values and the patient s usual patterns in a wide variety of instances. Examples of appropriate times to measure vital signs include, but are not limited to, screenings at health fairs and clinics, in the home, upon admission to a health care setting, when medications are given that may affect one of the vital signs, before and after invasive diagnostic and surgical procedures, and in emergency situations.  Assessing Body Temperature Body temperature is the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees. Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperature (intracranial, intrathoracic, and intra-abdominal) is higher than surface body temperature. Normal body temperature is 35.9 C to 37.5 C, depending on the route used for measurement. There are individual variations of these temperatures as well as variations related to age, gender, physical activity, state of health, and environmental temperatures. Body temperature also varies during the day, with temperatures being lowest in the early morning and highest in the late afternoon. Assessing Body Temperature Factors affecting the site selection include the patient s age, state of consciousness, amount of pain, and other care or treatments (e.g., oxygen administration) being provided. Several types of equipment and different procedures might be used to measure body temperature. To obtain an accurate measurement, choose an appropriate site, the correct equipment, and the appropriate tool based on the patient s condition. If a temperature reading is obtained from a site other than the oral route, document the site used along with the measurement. If no site is listed with the documentation, it is generally assumed to be the oral route.  Ibrahim Ayasreh RN, PhD, 2021 Assessing Body Temperature Glass thermometers with mercury-filled bulbs have been used in the past for measuring body temperature. Patients may still have mercury thermometers at home and may be continuing to use them. Nurses should encourage patients to use alternative devices to measure body temperature and include patient teaching as part of nursing care. Although bulb-type glass thermometers containing liquids other than mercury are available, they should never be used to measure the temperature of a person who is unconscious or irrational, or of infants and young children, because the glass could break.  Equipment Assessment Note baseline or previous temperature measurements. Assess the patient to ensure that his or her cognitive functioning is intact. Taking an oral temperature of a patient unable to follow directions can result in injury if the patient bites down on the thermometer. Assess whether the patient can close his or her lips around the thermometer. If the patient cannot, the oral method is not appropriate. Oral temperature measurement is contraindicated in patients with diseases of the oral cavity and in those who have had surgery of the nose or mouth. Ask the patient if he or she has recently smoked, has been chewing gum, or was eating and drinking immediately before having temperature assessed. If any of these have occurred, wait 30 minutes before taking an oral temperature because of the possible direct influence they may have on the patient s temperature.  Pre-Procedure Check PCP orders and the patient care plan. Gather supplies and equipment. Perform hand hygiene. Maintain standard precautions. Use of the correct personal protective equipment (PPE) is required whenever contact with bodily fluids is possible, to reduce the transfer of pathogens. Introduce yourself. Provide for patient privacy. Identify the patient, using two identifiers. Explain the procedure to the patient. Procedure (Oral) Obtain electronic thermometer with blue probe. Remove temperature probe; machine will beep and digital display will appear. Place probe in disposable cover; cover will click into place. Insert probe tip into posterior sublingual pocket of mouth, holding it along the side of the probe positioned slightly off the center of the jaw; patient's lips must be closed around probe.  Procedure (Oral) Hold probe in place until reading is completed; machine will beep to indicate measurement is completed. Remove probe from patient. Note temperature reading on display. Discard probe cover; push the eject button at the end of the probe to release cover into trash can. Ibrahim Ayasreh RN, PhD, 2021  Procedure (Rectal) Obtain electronic thermometer with red probe. Raise bed to comfortable working height and flatten bed as tolerated by patient. Position patient in Sims position, with upper leg flexed and lower leg straight. Promotes comfort; allows visualization of the buttocks. Apply clean gloves. Cover patient, except for buttocks. Procedure (Rectal) Remove temperature probe; machine will beep and digital display will appear. Place probe in disposable cover; cover will click into place. Apply water-soluble lubricant to 1 to 1.5 inch of the probe tip; can be done three different ways: a. Packets: Dip probe in packet. b. Direct application: Squeeze directly onto probe. c. Indirect application: Squeeze onto paper towel or tissue. Separate buttocks with one hand. Ask patient to breathe slowly and relax.  Procedure (Rectal) Insert probe tip 1 to 1.5 inches in adults, pointing toward the umbilicus (Rectal temperature measurement is contraindicated in young infants. Check facility policy for use in children). Hold probe in place until reading is completed; machine will beep to indicate measurement is completed. Remove probe from patient. Note temperature reading on display. Discard probe cover; push the eject button to release cover into trash can. Clean probe tip with alcohol wipe before returning probe to case. Clean patient; reposition. Ibrahim Ayasreh RN, PhD, 2021 https://www.youtube.com/watch?v=aSe6h sc8tJw  Procedure (Axillary) Obtain electronic thermometer with blue probe. Remove temperature probe; machine will beep and digital display will appear. Place probe in disposable cover; cover will click into place. Remove clothing from axillary area; place probe tip in middle of the axilla. Arm should be held down, close to the body or across chest. Hold probe in place until reading is completed; machine will beep to indicate measurement is completed. Remove probe from axilla. Note temperature reading on display. Discard probe cover; push end of probe to release cover into trash can. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 https://www.youtube.com/watch?v=aSe6h sc8tJw  Assessing Pulse Pulse is a wave of blood created by contraction of the left ventricle of the heart. The pulse is a throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery. Peripheral pulse is a pulse located away from the heart, for example, in the foot or wrist. Apical pulse is a central pulse; that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI).  Pulse Sites Assessing Pulse  Equipment Assessment Check medical order or nursing care plan for frequency of pulse assessment. Perform hand hygiene and put on PPE, if indicated. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient s ability to assist with the procedure. Put on gloves, if indicated. Gloves are not usually worn to obtain a pulse measurement unless contact with blood or body fluids is anticipated. Select the appropriate peripheral site based on assessment data. Move the patient s clothing to expose only the site chosen.  Assessment Place your first, second, and third fingers over the artery. Lightly compress the artery so pulsations can be felt and counted. Using a watch with a second hand, count the number of pulsations felt for 30 seconds (Figure 2). Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute. Note the rhythm and amplitude of the pulse. When measurement is completed, remove gloves, if worn. Cover the patient and help him or her to a position of comfort. Ibrahim Ayasreh RN, PhD, 2021  Assessing Apical Pulse Assessing Apical Pulse Check medical order or nursing care plan for frequency of pulse assessment. Perform hand hygiene and put on PPE, if indicated. Identify the patient. Close curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient s ability to assist with the procedure. Put on gloves, if indicated. Use an alcohol swab to clean the diaphragm of the stethoscope. Use another swab to clean the earpieces, if necessary.  Assessing Apical Pulse Assist the patient to a sitting or reclining position and expose the chest area. Move the patient s clothing to expose only the apical site. Hold the stethoscope diaphragm against the palm of your hand for a few seconds. Palpate the space between the fifth and sixth ribs (fifth intercostal space), and move to the left midclavicular line. Place the stethoscope diaphragm over the apex of the heart. Listen for heart sounds ( lub-dub ). Each lub-dub counts as one beat. Using a watch with a second hand, count the heartbeat for 1 minute. When measurement is completed, cover the patient and help him or her to a position of comfort. Clean the diaphragm of the stethoscope with an alcohol swab. Ibrahim Ayasreh RN, PhD, 2021  Assessing Respiration Under normal conditions, healthy adults breathe about 12 to 20 times per minute. Infants and children breathe more rapidly. The depth of respirations varies normally from shallow to deep. The rhythm of respirations is normally regular, with each inhalation/exhalation and the pauses between occurring at regular intervals. An irregular respiratory rhythm occurs when the inhalation/exhalation cycle and the pauses between occur at unequal intervals. Assess respiratory rate, depth, and rhythm by inspection (observing and listening) or by listening with the stethoscope. Determine the rate by counting the number of breaths per minute. If respirations are very shallow and difficult to detect, observe the sternal notch, where respiration is more apparent. Assessing Respiration While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient s respirations. Note the rise and fall of the patient s chest. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. If respirations are abnormal in any way, count the respirations for at least 1 full minute. Note the depth and rhythm of the respirations. Assessing Brachial Artery Blood Pressure Adopted by Mrs. Fedaa Ayasreh 2021 Blood pressure Blood pressure refers to the force of the moving blood against arterial walls. The pressure rises as the ventricle contracts (systole) and falls as the heart relaxes (diastole). The highest pressure is the systolic pressure. The lowest pressure present on arterial walls at this time is the diastolic pressure. The difference between the systolic and diastolic pressures is called the pulse pressure.  Blood pressure Blood pressure is measured in millimeters of mercury (mm Hg) and is recorded as a fraction. The numerator is the systolic pressure; the denominator is the diastolic pressure. For example, if the blood pressure is 120/80 mm Hg, 120 represents the systolic pressure, and 80 represents the diastolic pressure. The pulse pressure, in this case, is 40 mm Hg.  Assessing Blood Pressure EQUIPMENT: Stethoscope Sphygmomanometer Blood pressure cuff of appropriate size Pencil or pen, paper or flow sheet Alcohol swab Stethoscope  Sphygmomanometer A sphygmomanometer is used to assess blood pressure. The sphygmomanometer consists of a cuff and the manometer. Sphygmomanometer  Assessing Blood Pressure Perform hand hygiene and put on PPE, if indicated. Identify the patient. Close curtains around bed and close door to room if possible. the procedure. Select the appropriate arm for application of the cuff. Assessing Blood Pressure Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and the palm of the hand upward. If the arm is below the level of the heart, the readings will be too high. If the arm is above the level of the heart, the readings will be too low. If the measurement is taken in the supine position, support the arm with a pillow. If the patient is sitting, have the patient sit back in the chair so that the chair supports his or her back. In addition, make sure the patient keeps the legs uncrossed. If the back is not supported, the diastolic pressure may be elevated falsely. If the legs are crossed, the systolic pressure may be elevated falsely.  Ibrahim Ayasreh RN, PhD, 2021 Assessing Blood Pressure Expose the brachial artery by removing garments, or move a sleeve, if it is not too tight, above the area where the cuff will be placed. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 2) above the inner aspect of the elbow. The tubing should extend from the edge of the cuff nearer elbow. Ibrahim Ayasreh RN, PhD, 2021  Assessing Blood Pressure Wrap the cuff around the arm smoothly and snugly and fasten it. Do not allow any clothing to interfere with the proper placement of the cuff. Check that the needle on the aneroid gauge is within the zero mark. If using a mercury manometer, check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level.  Ibrahim Ayasreh RN, PhD, 2021 Estimating Systolic Pressure Palpate the pulse at the brachial or radial artery by pressing gently with the fingertips. Tighten the screw valve on the air pump. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. Deflate the cuff and wait 1 minute.  Obtaining Blood Pressure Measurement Assume a position that is no more than 3 feet away from the gauge. Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal and not against the ear itself. Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery. Do not allow the stethoscope to touch clothing or the cuff. Obtaining Blood Pressure Measurement Pump the pressure 30-mm Hg above the point at which the systolic pressure was palpated and estimated. Open the valve on the manometer and allow air to escape slowly (allowing the gauge to drop 2 3 mm per second). Note the point on the gauge at which the first faint, but clear, sound appears that slowly increases in intensity. Note this number as the systolic pressure reading. Do not reinflate the cuff once the air is being released to recheck the systolic pressure reading. Note the point at which the sound completely disappears (the diastolic pressure reading).  Obtaining Blood Pressure Measurement Allow the remaining air to escape quickly. When measurement is completed, remove the cuff. Remove gloves, if worn. Cover the patient and help him or her to a position of comfort. Perform hand hygiene. Clean the diaphragm of the stethoscope with the alcohol wipe. Clean and store the sphygmomanometer, according to facility policy. Ibrahim Ayasreh RN, PhD, 2021 Documentation  Oxygen Therapy Prepared by Fedaa Ayasreh Oxygen Therapy Oxygen is an odorless, tasteless, colorless, transparent gas. It is used to treat or prevent symptoms and manifestations of hypoxia.  Administering Oxygen by Nasal Cannula EQUIPMENT: Oxygen source Plastic nasal cannula (disposable) Humidifier filled with sterile water Flowmeter No smoking signs Cannula delivers a relatively low concentration of oxygen (24% to 45%) at flow rates of 2 to 6 L/min Oxygen sources WALL SOURCE Oxygen sources CYLINDER SOURCE Nasal cannula Humidifier Flowmeter  No smoking sign Administering Oxygen by Nasal Cannula Bring necessary equipment to the bedside stand or overbed table. Perform hand hygiene and put on PPE, if indicated. Identify the patient. Close curtains around bed and close door to room if possible. Explain what you are going to do and the reason for doing it to the patient.  Administering Oxygen by Nasal Cannula Connect nasal cannula to oxygen setup with humidification, if one is in use. Humidification prevents dehydration of the mucous membranes. Low-flow oxygen does not Require humidification.  Administering Oxygen by Nasal Cannula Place prongs in patient s nostrils. Place tubing over and behind each ear with adjuster comfortably under chin. Alternately, the tubing may be placed around the patient s head, with adjuster at the back or base of the head. Place gauze pads at ear under the tubing as necessary.  Administering Oxygen by Nasal Cannula Encourage patients to breathe through the nose, with the mouth closed. Reassess patient s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. Remove PPE, if used. Perform hand hygiene. Put on clean gloves. Remove and clean the cannula and assess nares at least every 8 hours.  Sample Documentation Simple Face mask The simple face mask delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 L/min  Administering Oxygen by Face Mask Verify correct patient. Show the simple face mask to the patient and explain the procedure. Make sure the humidifier is filled to appropriate mark. Attach the face mask to the humidifier outlet and oxygen source. Set the flow rate ad doctor order (liters per minute). Position facemask over the patients nose and mouth. Remove the mask and dry the skin every 2 to 3 hours, if the oxygen runs continuously.  Administering Oxygen by Face Mask Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. The tight-fitting mask and moisture from condensation can irritate the skin on the face. Do not use powder around the mask. There is a danger of inhaling powder if it is placed on the mask. Partial rebreather mask Partial rebreather mask has an inflatable bag that stores 100% oxygen. a. On inspiration, the patient inhales from the mask and bag; on expiration, the bag refills with oxygen and expired gases exit through perforations on both sides of the mask and some enters bag. b. High concentrations of oxygen (50% to 75%) can be delivered.  Partial rebreather mask Mask is a simple mask with a reservoir bag. Low flow, medium concentration 50 70% 8 12 liters per minute Bag should remain at least 1/3 full during inspiration Allow the mixture or oxygen and carbon dioxide in the mask. Non-Rebreathing Mask The one-way valve closes, and all the expired air is deposited into the atmosphere, not the reservoir bag. This mask provides the highest concentration of oxygen (95-100%) at a flow rate 8-15 L/min. It is similar to the partial rebreather mask except two one-way valves prevent conservation of exhaled air.  Inserting Nasogastric (NG) Tube Adopted by Mrs. Fedaa Ayasreh 2021 Inserting Nasogastric (NG) Tube The nasogastric (NG) tube is passed through the nose and into the stomach. Purposes of NG tube: It permits the patient to receive nutrition through a tube feeding using the stomach as a natural reservoir for food. It may be to decompress or to drain unwanted fluid and air from the stomach. It allow the intestinal tract to rest and promote healing after bowel surgery. To monitor bleeding in the gastrointestinal (GI) tract. To remove undesirable substances (lavage) such as poisons, or to help treat an intestinal obstruction.  Equipment Types of NG tubes Levine NG tube. Salem Sump NG tube Single lumen, small bore NG tube. It is Double lumen, equipped with a one-way more appropriate for administration of valve that allows air to enter and can medication or nutrition prevent reflux of gastric contents  Assessment Assess the patency of the patient s nares by asking the patient to occlude one nostril and breathe normally through the other. Select the nostril through which air passes more easily. Assess the patient s history for any recent facial trauma, polyps, blockages, or surgeries. Inspect the abdomen for distention. Auscultate for bowel sounds or peristalsis and palpate the abdomen for distention and tenderness.  Implementation Verify the medical order for insertion of an NG tube. Gather equipment, including selection of the appropriate NG tube. Perform hand hygiene and put on PPE, if indicated. Identify the patient. Explain the procedure to the patient, including the rationale for why the tube is needed. Implementation Close the patient s bedside curtain or door. Raise the bed to a comfortable working position, usually elbow height of the caregiver. Assist the patient to high Fowler s position or elevate the head of the bed 45 degrees if the patient is unable to maintain an upright position. Drape chest with bath towel or disposable pad. Have emesis basin and tissues handy.  Implementation Measure the distance to insert the tube by placing tube tip at the patient s nostril and extending it to tip of earlobe and then to tip of xiphoid process. Mark tube with an indelible marker.  Implementation Put on gloves. Lubricate tip of tube (at least 2 to 4 inches) with water-soluble lubricant. Apply topical anesthetic to nostril and oropharynx, as appropriate. After selecting the appropriate nostril, ask the patient to flex the head slightly back against the pillow. Gently insert the tube into the nostril while directing the tube upward and backward along the floor of the nose. Patient may gag when tube reaches pharynx. Provide tissues for tearing or watering of eyes.  Implementation When pharynx is reached, instruct the patient to touch chin to chest. Encourage the patient to sip water through a straw or swallow even if no fluids are permitted. Advance tube in downward and backward direction when patient swallows. In cooperation with the client, pass the tube 5 to 10 cm (2 to 4 in.) with each swallow, until the indicated length is inserted. Do not use force. Rotate the tube if it meets resistance.  Implementation Discontinue the procedure and remove the tube if there are signs of distress, such as gasping, coughing, cyanosis, and inability to speak or hum. Ascertain correct placement of the tube: Attach syringe to end of tube and aspirate a small amount of stomach contents. Check the pH, which should be acidic. Gastric contents are commonly pH 1 to 5. pH of 6 or greater would indicate the contents are from lower in the intestinal tract or in the respiratory tract. Gastric fluid can be green with particles, off-white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden- yellow color. Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus. Implementation Ascertain correct placement of the tube: Obtain radiograph (x-ray) of placement of tube, based on facility policy (and ordered by physician). Placing a stethoscope over the client s epigastrium and injected 10 to 30 mL of air into the tube while listening for a whooshing sound. This method does not guarantee tube position. Remove gloves and secure tube with tape to patient s nose: Cut a 4-inch piece of tape and split bottom 2 inches. Place unsplit end over bridge of patient s nose. Wrap split ends under and around NG tube Ibrahim Ayasreh RN, PhD, 2021  Implementation Put on gloves. Clamp tube and remove the syringe. Cap the tube or attach tube to suction. Measure length of exposed tube. Reinforce marking on tube at nostril with indelible ink. Ask the patient to turn his/her head to the side opposite the nostril in which the tube is inserted. Secure tube to patient s gown by using rubber band or tape and safety pin. Assist with or provide oral hygiene at 2- to 4-hour intervals. Lubricate the lips generously and clean nares and lubricate, as needed.  Medication Administration Adopted by Dr. Ibrahim Ayasreh RN, PhD 2021 Ibrahim Ayasreh RN, PhD, 2021 Administering Oral Medications Drugs given orally are intended for absorption in the stomach and small intestine. The oral route is the most commonly used route of administration. It is usually the most convenient and comfortable route for the patient. After oral administration, drug action has a slower onset and a more prolonged, but less potent, effect than other routes.  Ibrahim Ayasreh RN, PhD, 2021 Equipment Medication in disposable cup or oral syringe. Liquid (e.g., water, juice) with straw, if not contraindicated. Medication cart or tray. Computer-generated Medication Administration. Record (CMAR) or Medication Administration Record (MAR). PPE, as indicated. Ibrahim Ayasreh RN, PhD, 2021 Medication Records  Ibrahim Ayasreh RN, PhD, 2021 Assessment Assess the appropriateness of the drug for the patient. Review medical history, allergy, assessment, and laboratory data that may influence drug administration. Assess the patient s ability to swallow medications; check the gag reflex, if indicated. If the patient cannot swallow, is NPO, does not have gag reflex, or is experiencing nausea or vomiting, withhold the medication, notify the primary care provider, and complete proper documentation. Assess the patient s knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication. If the medication may affect the patient s vital signs, assess them before administration. If the medication is for pain relief, assess the patient s pain level before and after administration. Verify the patient name, dose, route, and time of administration. Ibrahim Ayasreh RN, PhD, 2021 Nursing Diagnosis Determine related factors for the nursing diagnoses based on the patient s current status. Appropriate nursing diagnoses may include: Impaired Swallowing Deficient Knowledge Risk for Aspiration  Ibrahim Ayasreh RN, PhD, 2021 Outcome Identification and Planning The expected outcome to achieve when administering an oral medication is that: The patient will swallow the medication. The patient will experience the desired effect from the medication. The patient will not aspirate. The patient experiences decreased anxiety. The patient does not experience adverse effects. The patient understands and complies with the medication regimen. Ibrahim Ayasreh RN, PhD, 2021 Implementation Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations. Prepare the required medications: Unit dose packages: Place unit dose-packaged medications in a disposable cup. Do not open the wrapper until at the bedside. Multidose containers: When removing tablets or capsules from a multidose bottle, pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Break only scored tablets, if necessary, to obtain the proper dosage. Do not touch tablets or capsules with hands. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Implementation Prepare the required medications: Liquid medication in multidose bottle: When pouring liquid medications out of a multidose bottle, hold the bottle so the label is against the palm. Use the appropriate measuring device when pouring liquids, and read the amount of medication at the bottom of the meniscus at eye level. Wipe the lip of the bottle with a paper towel. Ibrahim Ayasreh RN, PhD, 2021 Implementation Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, recheck the labels with the CMAR/MAR before taking the medications to the patient. Replace any multidose containers in the patient s drawer or unit stock. Lock the medication cart before leaving it. Transport medications to the patient s bedside carefully, and keep the medications in sight at all times. Ensure that the patient receives the medications at the correct time. Perform hand hygiene and put on PPE, if indicated.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Identify the patient. Compare the information with the CMAR/MAR. The patient should be identified using at least two methods. Complete necessary assessments before administering medications. Check the patient s allergy bracelet or ask the patient about allergies. Explain the purpose and action of each medication to the patient. Ibrahim Ayasreh RN, PhD, 2021 Implementation Assist the patient to an upright or lateral (side-lying) position. Administer medications: Offer water or other permitted fluids with pills, capsules, tablets, and some liquid medications. Ask whether the patient prefers to take the medications by hand or in a cup. Remain with the patient until each medication is swallowed. Never leave medication at the patient s bedside. Assist the patient to a comfortable position. Remove PPE, if used. Perform hand hygiene. Document the administration of the medication immediately after administration. Evaluate the patient s response to the medication within the appropriate time frame  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Unexpected Situations and Associated Interventions Patient states that it feels like medication is lodged in throat: Offer patient more fluids to drink. If allowed, offer the patient bread or crackers to help move the medication to the stomach. It is unclear whether the patient swallowed the medication: Check in the patient s mouth, under tongue, and between cheek and gum. Patient vomits immediately or shortly after receiving oral medication: Assess vomit, looking for pills or fragments. Do not re-administer medication without notifying primary care provider. If a whole pill is seen and can be identified, the primary care provider may ask that the medication be administered again. If a pill is not seen or medications cannot be identified, do not re-administer the medication in order to prevent the patient from receiving too large a dose.  Ibrahim Ayasreh RN, PhD, 2021 Unexpected Situations and Associated Interventions Capsule or tablet falls to the floor during administration: Discard and obtain a new dose for administration. This prevents contamination and transmission of microorganisms. Patient refuses medication: Explore the reason for the patient s refusal. Review the rationale for using the drug and any other information that may be appropriate. If you are unable to administer the medication despite education and discussion, document the omission according to facility policy and notify the primary care provider. Ibrahim Ayasreh RN, PhD, 2021 Removing Medication from an Ampule An ampule is a glass flask that contains a single dose of medication for parenteral administration. Because there is no way to prevent contamination of any unused portion of medication after the ampule is opened, discard any remaining medication if not all the medication is used for the prescribed dose. You must break the thin neck of the ampule to remove the medication.  Ibrahim Ayasreh RN, PhD, 2021 Equipment Sterile syringe and filter needle. Ampule of medication. Small gauze pad. Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR). Ibrahim Ayasreh RN, PhD, 2021 Assessment Assess the medication in the ampule for any particles or discoloration. Assess the ampule for any cracks or chips. Check expiration date before administering the medication. Verify patient name, dose, route, and time of administration. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration.  Ibrahim Ayasreh RN, PhD, 2021 Nursing Diagnosis Determine related factors for the nursing diagnoses based on the patient s current status. Appropriate nursing diagnoses may include: Risk for Infection. Risk for Injury. Deficient Knowledge. Ibrahim Ayasreh RN, PhD, 2021 Outcome Identification and Planning The expected outcome to achieve when removing medication from an ampule is that the medication will be removed in a sterile manner; it will be free from glass shards and the proper dose prepared  Ibrahim Ayasreh RN, PhD, 2021 Implementation Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer. Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations. Ibrahim Ayasreh RN, PhD, 2021 Implementation Tap the stem of the ampule or twist your wrist quickly while holding the ampule vertically. This facilitates movement of medication in the stem to the body of the ampule. Wrap a small gauze pad around the neck of the ampule. Use a snapping motion to break off the top of the ampule along the scored line at its neck. Always break away from your body.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Attach filter needle to syringe. Remove the cap from the filter needle by pulling it straight off. Withdraw medication in the amount ordered plus a small amount more (approximately 30% more). Do not inject air into the solution. While inserting the filter needle into the ampule, be careful not to touch the rim. Use either of the following methods to withdraw the medication: Insert the tip of the needle into the ampule, which is upright on a flat surface, and withdraw fluid into the syringe. Touch the plunger only at the knob. Insert the tip of the needle into the ampule and invert the ampule. Keep the needle centered and not touching the sides of the ampule. Withdraw fluid into syringe. Touch the plunger only at the knob. Wait until the needle has been withdrawn to tap the syringe and expel the air carefully by pushing on the plunger. Check the amount of medication in the syringe with the medication dose and discard any surplus. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Implementation Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, recheck the labels with the CMAR/MAR before taking the medications to the patient. Engage safety guard on filter needle and remove the needle. Discard the filter needle in a suitable container. The filter needle used to draw up medication should not be used to administer the medication. Discard the ampule in a suitable container. Any medication that has not been removed from the ampule must be discarded because sterility of contents cannot be maintained in an opened ampule. Lock the medication cart before leaving it. Ibrahim Ayasreh RN, PhD, 2021 https://www.youtube.com/watch?v=mFKj3_Wk8m8  Ibrahim Ayasreh RN, PhD, 2021 Removing Medication From a Vial A vial is a glass bottle with a self-sealing stopper through which medication is removed. For safety in transporting and storing, the vial top is usually covered with a soft metal cap that can be removed easily. The self-sealing stopper that is then exposed is the means of entrance into the vial. Single-dose vials are used once, and then discarded, regardless of the amount of the drug that is used from the vial. Multidose vials contain several doses of medication and can be used multiple times. The Centers for Disease Control and Prevention (CDC) recommends that medications packaged as multiuse vials be assigned to a single patient whenever possible (CDC, 2011). In addition, it is recommended that the top of the vial be cleaned before each entry, and that a new sterile needle and syringe are used for each entry. The medication contained in a vial can be in liquid or powder form. Powdered forms must be dissolved in an appropriate diluent before administration. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Equipment Sterile syringe and needle (size depends on medication being administered) Vial of medication Antimicrobial swab Second needle (optional) Filter needle (optional) Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR) Ibrahim Ayasreh RN, PhD, 2021 Assessment Assess the medication in the vial for any discoloration or particles. Check expiration date before administering medication. Verify patient name, dose, route, and time of administration. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration.  Ibrahim Ayasreh RN, PhD, 2021 Nursing Diagnosis Determine related factors for the nursing diagnoses based on the patient s current status. Appropriate nursing diagnoses may include: Risk for Infection. Risk for Injury. Deficient Knowledge. Ibrahim Ayasreh RN, PhD, 2021 Outcome Identification and Planning The expected outcome to achieve when removing medication from a vial is withdrawal of the medication into a syringe in a sterile manner and preparation of the proper dose.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer. Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations. Ibrahim Ayasreh RN, PhD, 2021 Implementation Remove the metal or plastic cap on the vial that protects the rubber stopper. Swab the rubber top with the antimicrobial swab and allow to dry. Remove the cap from the needle by pulling it straight off. Touch the plunger only at the knob. Draw back an amount of air into the syringe that is equal to the specific dose of medication to be withdrawn. Hold the vial on a flat surface. Pierce the rubber stopper in the center with the needle tip and inject the measured air into the space above the solution. Do not inject air into the solution. Invert the vial. Keep the tip of the needle below the fluid level. Hold the vial in one hand and use the other to withdraw the medication. Touch the plunger only at the knob. Draw up the prescribed amount of medication while holding the syringe vertically and at eye level  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Implementation If any air bubbles accumulate in the syringe, tap the barrel of the syringe sharply and move the needle past the fluid into the air space to re-inject the air bubble into the vial. Return the needle tip to the solution and continue withdrawal of the medication. After the correct dose is withdrawn, remove the needle from the vial and carefully replace the cap over the needle. If a filter needle has been used to draw up the medication, remove it and attach the appropriate administration device. Check the amount of medication in the syringe with the medication dose and discard any surplus. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, recheck the labels with the CMAR/MAR before taking the medications to the patient.  Ibrahim Ayasreh RN, PhD, 2021 Implementation If a multidose vial is being used, label the vial with the date and time opened, and store the vial containing the remaining medication according to facility policy. Lock the medication cart before leaving it. Perform hand hygiene. Proceed with administration, based on prescribed route. https://www.youtube.com/watch?v=6buCd7-nt_0 Ibrahim Ayasreh RN, PhD, 2021 Reconstituting Powdered Medication in a Vial Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer. Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations.  Ibrahim Ayasreh RN, PhD, 2021 Reconstituting Powdered Medication in a Vial Remove the metal or plastic cap on the medication vial and diluent vial that protects the self- sealing stoppers. Swab the self-sealing tops with the antimicrobial swab and allow to dry. Draw up the appropriate amount of diluent into the syringe. Insert the needle through the center of the self-sealing stopper on the powdered medication vial. Inject the diluent into the powdered medication vial. Remove the needle from the vial and replace cap. Gently agitate the vial to mix the powdered medication and the diluent completely. Do not shake the vial. Draw up the prescribed amount of medication while holding the syringe vertically and at eye level. Ibrahim Ayasreh RN, PhD, 2021 Reconstituting Powdered Medication in a Vial Draw up the prescribed amount of medication while holding the syringe vertically and at eye level. After the correct dose is withdrawn, remove the needle from the vial and carefully replace the cap over the needle. If a filter needle has been used to draw up the medication, remove it and attach the appropriate administration device. Check the amount of medication in the syringe with the medication dose and discard any surplus. Depending on facility policy, the third check of the label may occur at this point. If so, recheck the label with the CMAR/MAR before taking the medications to the patient. Lock the medication cart before leaving it. Perform hand hygiene. Proceed with administration, based on prescribed route.  Ibrahim Ayasreh RN, PhD, 2021 https://www.youtube.com/watch?v=8ECYuiHFObU Ibrahim Ayasreh RN, PhD, 2021 Administering an Intradermal Injection Intradermal injections are administered into the dermis, just below the epidermis. The intradermal route has the longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia. The advantage of the intradermal route for these tests is that the body s reaction to substances is easily visible, and degrees of reaction are discernible by comparative study. Sites commonly used are the inner surface of the forearm and the upper back, under the scapula. Equipment used for an intradermal injection includes a tuberculin syringe calibrated in tenths and hundredths of a milliliter and a 0.25- to 0.5-inch, 25- or 27-gauge needle. The dosage given intradermally is small, usually less than 0.5 mL. The angle of administration for an intradermal injection is 5 to 15 degrees.  Ibrahim Ayasreh RN, PhD, 2021 Equipment Prescribed medication. Sterile syringe, usually a tuberculin syringe calibrated in tenths and hundredths, and a needle, - -inch, 25- or 27-gauge. Antimicrobial swab. Disposable gloves. Small gauze square Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR). PPE, as indicated. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Assessment Assess the patient for any allergies. Check expiration date before administering medication. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration. Assess the site on the patient where the injection is to be given. Avoid areas of broken or open skin. Avoid areas that are highly pigmented, and those that have lesions, bruises, or scars and are hairy. Verify the patient s name, dose, route, and time of administration.. Ibrahim Ayasreh RN, PhD, 2021 Nursing Diagnosis Determine related factors for the nursing diagnoses based on the patient s current status. Appropriate nursing diagnoses may include: Risk for Infection. Risk for Injury. Deficient Knowledge.  Ibrahim Ayasreh RN, PhD, 2021 Outcome Identification and Planning The expected outcome to achieve when administering an intradermal injection is the appearance of a wheal at the injection site. Other outcomes that may be appropriate include the following: the patient refrains from rubbing the site; the patient s anxiety is decreased; the patient does not experience adverse effects; and the patient understands and complies with the medication regimen. Ibrahim Ayasreh RN, PhD, 2021 Implementation Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer. Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations.  Ibrahim Ayasreh RN, PhD, 2021 Implementation If necessary, withdraw the medication from an ampule or vial. Put on clean gloves. Gloves help prevent exposure to contaminants. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape, as needed, to expose only site area to be used. Cleanse the site with an antimicrobial swab while wiping with a firm, circular motion and moving outward from the injection site. Allow the skin to dry. Remove the needle cap with the nondominant hand by pulling it straight off. Use the nondominant hand to spread the skin taut over the injection site. Hold the syringe in the dominant hand, between the thumb and forefinger with the bevel of the needle up. Ibrahim Ayasreh RN, PhD, 2021 Implementation Hold the syringe at a 5- to 15-degree angle from the site. Place the needle almost flat against the patient s skin, bevel side up, and insert the needle into the skin. Insert the needle only about 1 8 inch with entire bevel under the skin. Once the needle is in place, steady the lower end of the syringe. Slide your dominant hand to the end of the plunger. Slowly inject the agent while watching for a small wheal or blister to appear.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Implementation Withdraw the needle quickly at the same angle that it was inserted. Do not recap the used needle. Do not massage the area after removing needle. Tell the patient not to rub or scratch the site. If necessary, gently blot the site with a dry gauze square. Do not apply pressure or rub the site. Assist the patient to a position of comfort. Discard the needle and syringe in the appropriate receptacle. Remove gloves and additional PPE, if used. Perform hand hygiene. Document the administration of the medication immediately after administration. Evaluate the patient s response to the medication within the appropriate time frame. Observe the area for signs of a reaction at determined intervals after administration. Inform the patient of the need for inspection.  Ibrahim Ayasreh RN, PhD, 2021 Documentation Guidelines Record each medication administered on the CMAR/MAR or record using the required format, including date, time, and the site of administration, immediately after administration. Some facilities recommend circling the injection site with ink. Circling the injection site easily identifies the intradermal injection site and allows for future careful observation of the exact area. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the primary care provider. on type of reaction and patient assessment. Ibrahim Ayasreh RN, PhD, 2021 Administering a Subcutaneous Injection Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. This tissue has few blood vessels, so drugs administered here have a slow, sustained rate of absorption into the capillaries. It is important to choose the right equipment to ensure depositing the medication into the intended tissue layer and not the underlying muscle. A 25- to 30-gauge, 3 8- to 1-inch needle can be used; 3 8- and 5 8-inch needles are most commonly used for subcutaneous injections Various sites may be used for subcutaneous injections, including the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crests), the anterior aspects of the thigh, the upper back, and the upper ventral gluteal area.  Ibrahim Ayasreh RN, PhD, 2021 Administering a Subcutaneous Injection Injections in the abdomen are absorbed most rapidly; ones in the arms are absorbed somewhat more slowly; those in the thighs, even more slowly; and those in the upper ventral or dorsogluteal areas have the slowest absorption. Subcutaneous injections are administered at a 45- to 90-degree angle. Choose the angle of needle insertion based on the amount of subcutaneous tissue present and the length of the needle. Generally, insert the shorter, 3 8-inch needle, at a 90-degree angle and the longer, 5 8-inch needle, at a 45-degree angle Recommendations differ regarding pinching or bunching a skin fold for administration. Pinching is advised for thinner patients and when a longer needle is used, to lift the adipose tissue away from underlying muscle and tissue. If pinching is used, once the needle is inserted, release the skin to avoid injecting into the compressed tissue. Usually, no more than 1 mL of solution is given subcutaneously. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Equipment Prescribed medication. Sterile syringe and needle. Antimicrobial swab. Disposable gloves. Small gauze square Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR). PPE, as indicated.  Ibrahim Ayasreh RN, PhD, 2021 Assessment Assess the patient for any allergies. Check expiration date before administering medication. Assess the appropriateness of the drug for the patient. Review assessment and laboratory data that may influence drug administration. Assess the site on the patient where the injection is to be given. Avoid sites that are bruised, tender, hard, swollen, inflamed, or scarred. These conditions could affect absorption or cause discomfort and injury. Verify the patient s name, dose, route, and time of administration.. Ibrahim Ayasreh RN, PhD, 2021 Nursing Diagnosis Determine related factors for the nursing diagnoses based on the patient s current status. Appropriate nursing diagnoses may include: Acute pain. Risk for Injury. Deficient Knowledge.  Ibrahim Ayasreh RN, PhD, 2021 Outcome Identification and Planning The expected outcome is that the patient receives the medication via the subcutaneous route. Other outcomes that may be appropriate include the following: the patient s anxiety is decreased; the patient does not experience adverse effects; and the patient understands and complies with the medication regimen. Ibrahim Ayasreh RN, PhD, 2021 Implementation Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer. Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Put on clean gloves. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape, as needed, to expose only site area to be used. Identify the appropriate landmarks for the site chosen. Cleanse the area around the injection site with an antimicrobial swab. Use a firm, circular motion while moving outward from the injection site (Figure 3). Allow the area to dry. Remove the needle cap with the nondominant hand, pulling it straight off. Grasp and bunch the area surrounding the injection site or spread the skin taut at the site. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Implementation Hold the syringe in the dominant hand between the thumb and forefinger. Inject the needle quickly at a 45- to 90-degree angle. After the needle is in place, release the tissue. If you have a large skin fold pinched up, ensure that the needle stays in place as the skin is released. Immediately move your nondominant hand to steady the lower end of the syringe. Slide your dominant hand to the end of the plunger. Avoid moving the syringe. Inject the medication slowly (at a rate of 10 sec/mL). Withdraw the needle quickly at the same angle at which it was inserted, while supporting the surrounding tissue with your nondominant hand. Using a gauze square, apply gentle pressure to the site after the needle is withdrawn. Do not massage the site. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Administering Intramuscular Injection Injections into muscle tissue, or intramuscular (IM) injections, are absorbed more quickly than subcutaneous injections because of the greater blood supply to the body muscles. Muscles can also take a larger volume of fluid without discomfort than subcutaneous tissues can, although the amount varies among individuals, chiefly based on muscle size and condition and the site used. An adult with well-developed muscles can usually safely tolerate up to 3 mL of medication in the gluteus medius and gluteus maximus muscles. A volume of 1 to 2 mL is usually recommended for adults with less-developed muscles. In the deltoid muscle, volumes of 0.5 to 1 mL are recommended. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Equipment Disposable gloves Additional PPE, as indicated Medication Sterile syringe and needle of appropriate size and gauge Antimicrobial swab Small gauze square Computer-generated Medication Administration Record (CMAR) or Medication Administration Record (MAR)  Ibrahim Ayasreh RN, PhD, 2021 Implementation Gather equipment. Check each medication order against the original in the medical record. Perform hand hygiene. Move the medication cart to the outside of the patient s room or prepare for administration in the medication area. Unlock the medication cart or drawer. Enter pass code into the computer and scan employee identification, if required. Prepare medications for one patient at a time. Read the CMAR/MAR and select the proper medication from the unit stock or patient s medication drawer. Compare the medication label with the CMAR/MAR. Check expiration dates and perform calculations. Ibrahim Ayasreh RN, PhD, 2021 Implementation If necessary, withdraw medication from an ampule or vial, as described before. When all medications for one patient have been prepared, recheck the label with the MAR before taking them to the patient. Close the door to the room or pull the bedside curtain. Scan the patient s bar code on the identification band, if required. Put on clean gloves. Select an appropriate administration site. Assist the patient to the appropriate position for the site chosen. Drape as needed to expose only the area of site being used  Ibrahim Ayasreh RN, PhD, 2021 Implementation Identify the appropriate landmarks for the site chosen. Cleanse the area around the injection site with an antimicrobial swab. Use a firm, circular motion while moving outward from the injection site. Allow area to dry. Remove the needle cap by pulling it straight off. Hold the syringe in your dominant hand between the thumb and forefinger. Displace the skin in a Z-track manner by pulling the skin down or to one side about 1 inch (2.5 cm) with your nondominant hand and hold the skin and tissue in this position. Quickly dart the needle into the tissue so that the needle is perpendicular to the patient s body. This should ensure that it is given using an angle of injection between 72 and 90 degrees. Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Implementation As soon as the needle is in place, use the thumb and forefinger of your nondominant hand to hold the lower end of the syringe. Slide your dominant hand to the end of the plunger. Inject the solution slowly (10 seconds per milliliter of medication). Once the medication has been instilled, wait 10 seconds before withdrawing the needle. Withdraw the needle smoothly and steadily at the same angle at which it was inserted, supporting tissue around the injection site with your nondominant hand. Apply gentle pressure at the site with a dry gauze. Do not massage the site  Ibrahim Ayasreh RN, PhD, 2021 Implementation Assist the patient to a position of comfort. Remove gloves and additional PPE, if used. Perform hand hygiene. Document the administration of the medication immediately after administration. Evaluate patient s response to medication within an appropriate time frame. Assess site, if possible, within 2 to 4 hours after administration.  Parenteral Fluid Therapy Adopted by Dr. Ibrahim Ayasreh RN, PhD 2021 Ibrahim Ayasreh RN, PhD, 2021 Parenteral Fluid Therapy When no other route of administration is available, fluids are given by IV in hospitals, outpatient diagnostic and surgical settings, clinics, and homes to replace fluids, administer medications, and provide nutrients. The choice of an IV solution depends on the purpose of its administration. Purposes of IV therapy: To provide water, electrolytes, and nutrients to meet daily requirements. To replace water and correct electrolyte deficits. To administer medications and blood products.  Ibrahim Ayasreh RN, PhD, 2021 Parenteral Fluid Therapy IV fluids are classified broadly as crystalloids or colloids. Crystalloids are solutions with small molecules, usually electrolytes that are able to pass through cell membranes. These fluids are used primarily for fluid and electrolyte maintenance and replacement. IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture. Solutions are often categorized as isotonic, hypotonic, or hypertonic, according to whether their total osmolality is the same as, less than, or greater than that of blood, respectively. Ibrahim Ayasreh RN, PhD, 2021 Parenteral Fluid Therapy Electrolyte solutions are considered Isotonic if the total electrolyte content (anions + cations) is between 250 and 375 mEq/L. Hypotonic if the total electrolyte content is less than 250 mEq/L. Hypertonic if the total electrolyte content is greater than 375 mEq/L. The nurse must also consider a solution s osmolality, keeping in mind that the osmolality of plasma is approximately 300 mOsm/L (300 mmol/L).  Ibrahim Ayasreh RN, PhD, 2021 Isotonic Fluids Fluids that are classified as isotonic have a total osmolality close to that of the ECF and do not cause red blood cells to shrink or swell. Isotonic fluids expand the ECF volume. One liter of isotonic fluid expands the ECF by 1 L; however, it expands the plasma by only 0.25 L because it is a crystalloid fluid and diffuses quickly into the ECF compartment. For the same reason, 3 L of isotonic fluid is needed to replace 1 L of blood loss. Ibrahim Ayasreh RN, PhD, 2021 Isotonic Fluids D5W: A solution of D5W is unique in that it may be both isotonic and hypotonic. Once given, the glucose is rapidly metabolized, and this initially isotonic solution then disperses as a hypotonic fluid one third extracellular and two thirds intracellular. During fluid resuscitation, this solution should not be used because hyperglycemia can result. Therefore, D5W is used mainly to supply water and to correct an increased serum osmolality. About 1 L of D5W provides less than 170 kcal and is a minor source of the body s daily caloric requirements. D5W is avoided in clients at risk for increased intracranial pressure (IICP) because it can increase cerebral edema.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Isotonic Fluids Normal Saline Solution: Normal saline (0.9% sodium chloride) solution contains water, salt, and chloride. Because the osmolality is entirely contributed by electrolytes, the solution remains within the ECF. For this reason, normal saline solution is often used to correct an extracellular volume deficit. It is used with administration of blood transfusions and to replace large sodium losses, such as in burn injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. Normal saline does not supply calories.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Isotonic Fluids Lactated Ringer: Lactated Ringer solution contains potassium and calcium in addition to sodium chloride. It is used to correct dehydration and sodium depletion and replace GI losses. Used when there is loss of fluid and electrolytes, as in burns, severe diarrhea, or during surgery. Lactated Ringer s solution is an alkalizing solution that may be given to treat metabolic acidosis. Do not use in patients with renal or liver disease.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Hypotonic Fluids One purpose of hypotonic solutions is to replace cellular fluid, because it is hypotonic compared with plasma. Another is to provide free water for excretion of body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia. 0.45% NaCl (half normal saline) and 0.33% NaCl (one-third normal saline) are frequently used. Excessive infusions of hypotonic solutions can lead to intravascular fluid depletion, decreased blood pressure, cellular edema, and cell damage.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Hypertonic Fluids Hypertonic solutions draw fluid out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume. These solutions increase the osmotic pressure of plasma and force fluids to move out of the cell and into the bloodstream. This can lead to cellular dehydration and fluid volume overload. Hypertonic solutions can be especially irritating to peripheral veins and the sites must be closely monitored.  Ibrahim Ayasreh RN, PhD, 2021 Hypertonic Fluids Ibrahim Ayasreh RN, PhD, 2021 Initiating a Peripheral Venous Access IV Infusion IV solution, as prescribed. Medication administration record (MAR). Towel or disposable pad. Nonallergenic tape IV administration set Label for infusion set (for next change date) Electronic infusion device (if appropriate). Tourniquet. Time tape and/or label (for IV container) Cleansing swabs. Clean gloves IV pole IV catheter Short extension tubing End cap for extension tubing Alcohol or other disinfectant wipes. Prefilled 2-mL syringe with sterile normal saline for injection.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Prepare the IV Solution and Administration Set Verify the IV solution order on the MAR/CMAR with the medical order. Perform hand hygiene and put on PPE, if indicated. Identify the patient. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Compare the IV container label with the MAR/CMAR. Remove IV bag from outer wrapper, if indicated. Check expiration dates. Label the solution container with the patient s name, solution type, date, and time.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Prepare the IV Solution and Administration Set Maintain aseptic technique when opening sterile packages and IV solution. Remove administration set from package. Apply label to tubing reflecting the day/date for next set change. Close the roller clamp or slide the clamp on the IV administration set. Invert the IV solution container and remove the cap on the entry site, taking care not to touch the exposed entry site. Remove the cap from the spike on the administration set. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Prepare the IV Solution and Administration Set Hang the IV container on the IV pole. Squeeze the drip chamber and fill at least halfway. Open the IV tubing clamp, and allow fluid to move through tubing. Allow fluid to flow until all air bubbles have disappeared and the entire length of the tubing is primed (filled) with IV solution. Close the clamp. Alternately, some brands of tubing may require removal of the cap at the end of the IV tubing to allow fluid to flow. Maintain its sterility. After fluid has filled the tubing, recap the end of the tubing.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Review the patient s record for baseline data, such as vital signs, intake and output balance, and related laboratory values, such as serum electrolytes. Assess the appropriateness of the solution for the patient. Determine the most desirable accessible vein: The dorsal and ventral surfaces of the upper extremities are appropriate sites for infusion. The superficial veins on the dorsal aspect of the hand can also be used successfully for some people, but can be more painful. Avoid the ventral surface of the wrist and the lateral surface of the wrist for approximately 4 to 5 inches because of the potential risk for nerve damage. Initiate venous access in the distal areas of the upper extremities, as this allows for future sites proximal to the previous insertion site. Usually the nondominant arm is selected for patient comfort and to limit movement in the impacted extremity. Do not use the antecubital veins if another vein is available. They are not a good choice for infusion because flexion of the patient s arm can displace the IV catheter over time. Do not use veins in the leg of an adult, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications.  Ibrahim Ayasreh RN, PhD, 2021 Commonly used venipuncture sites Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Place patient in low-Fowler s position in bed. Place protective towel or pad under patient s arm. Dilate the vein. Place the extremity in a dependent position (lower than the client s heart). Apply a tourniquet firmly 15 to 20 cm (6 to 8 in.) above the venipuncture site. Explain that the tourniquet will feel tight. Use the tourniquet on only one client. This avoids cross contamination to other clients. For older adults with fragile skin, instead of applying a tourniquet, place the arm in a dependent position to allow the veins to engorge. If the vein is not sufficiently dilated: Massage or stroke the vein distal to the site and in the direction of venous flow toward the heart. Encourage the client to clench and unclench the fist. Lightly tap the vein with your fingertips. If the preceding steps fail to distend the vein so that it is palpable, remove the tourniquet and wrap the extremity in a warm towel for 10 to 15 minutes. Then repeat steps to dilate the vein. Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Apply clean gloves and clean the venipuncture site. Clean the skin at the site of entry with a topical antiseptic swab (e.g., 2% chlorhexidine, or alcohol). Some institutions may use an anti-infective solution such as povidone-iodine (check agency protocol). When using chlorhexidine solution (preferred), use a back and forth motion for a minimum of 30 seconds to scrub the insertion site and surrounding area. Allow the site to completely air dry before inserting the catheter. Do not fan, blow on, or wipe the skin. When using povidone-iodine, apply using swab sticks in a concentric circle beginning at the catheter insertion site and moving outward. The iodine should be in contact with the skin for 2 minutes or longer to completely dry for adequate antisepsis  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Insert the catheter and initiate the infusion. Remove the catheter assembly from its sterile packaging. Use the nondominant hand to pull the skin taut below the entry site. Holding the over-the-needle catheter at a 15- to 30-degree angle with needle (stylet) bevel up, insert the catheter through the skin and into the vein. A sudden lack of resistance is felt as the needle (stylet) enters the vein. Use a slow steady insertion technique and avoid jabbing or stabbing motions. Once blood appears in the lumen or clear flashback chamber of the needle, lower the angle of the catheter until it is almost parallel with the skin, and advance the needle (stylet) and catheter approximately 0.5 to 1 cm (about 1/4 in.) farther. Holding the needle assembly steady, advance the catheter until the hub is at the venipuncture site.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Release the tourniquet. Put pressure on the vein proximal to the catheter to eliminate or reduce blood oozing out of the catheter. Stabilize the hub with thumb and index finger of the nondominant hand. Remove the protective cap from the distal end of the tubing and hold it ready to attach to the catheter, maintaining the sterility of the end. Stabilize the catheter hub and apply pressure distal to the catheter with your finger. Carefully remove the stylet, and attach the end of the infusion tubing to the catheter hub. Place the stylet directly into a sharps container. Initiate the infusion or flush the catheter with sterile normal saline.  Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Insert the catheter and initiate the infusion. If there is no blood return, try redirecting the catheter assembly again toward the vein. If the stylet has been withdrawn from the catheter even a small distance, or the catheter tip has been pulled out of the skin, the catheter must be discarded and a new one used. If blood begins to flow out of the vein into the tissues as the catheter is inserted, creating a hematoma, the insertion has not been successful. This is sometimes referred to as a blown vein. Immediately release the tourniquet and remove the catheter, applying pressure over the insertion site with dry gauze. Attempt the venipuncture in another site, in the opposite arm if possible. Ibrahim Ayasreh RN, PhD, 2021 Initiate Peripheral Venous Access Watch closely for any signs that the catheter is infiltrated. Infiltration occurs when the tip of the IV is outside the vein and the fluid is entering the tissues instead. It is manifested by localized swelling, coolness, pallor, and discomfort at the IV site. Stabilize the catheter and apply a dressing. Label the dressing with the date and time of insertion, gauge, and your initials. Discard the tourniquet. Remove and discard gloves. Perform hand hygiene. Ensure appropriate infusion flow. Label the IV tubing with the date and time of attachment and your initials. Document all assessments and interventions.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 https://www.youtube.com/watch?v=NuQz HwkP8bg https://www.youtube.com/watch?v=vE99r Z7JT3Q&t=88s Cleaning a Wound and Applying a Dry, Sterile Dressing Adopted by Dr. Ibrahim Ayasreh RN, PhD 2021 Ibrahim Ayasreh RN, PhD, 2021 Cleaning a Wound and Applying a Dry, Sterile Dressing The goal of wound care is to promote tissue repair and regeneration to restore skin integrity. Often, wound care includes cleaning of the wound and the use of a dressing as a protective covering over the wound. Wound cleansing is performed to remove debris, contaminants, and excess exudate. Sterile normal saline or a commercially prepared cleanser is the preferred cleansing solution. There is no standard frequency for how often dressings should be changed. It is customary for the surgeon or other advanced practice professional to perform the first dressing change on a surgical wound, usually within 24 to 48 hours after surgery.  Ibrahim Ayasreh RN, PhD, 2021 Equipment Ibrahim Ayasreh RN, PhD, 2021 Equipment  Ibrahim Ayasreh RN, PhD, 2021 Assessment Assess the situation to determine the need for wound cleaning and a dressing change. Confirm any medical orders relevant to wound care and any wound care included in the nursing plan of care. Assess the patient s level of comfort and the need for analgesics before wound care. Assess if the patient experienced any pain related to prior dressing changes and the effectiveness of interventions employed to minimize the patient s pain. Assess the current dressing to determine if it is intact. Assess for excess drainage, bleeding, or saturation of the dressing. Inspect the wound and the surrounding tissue. Assess the appearance of the wound for the approximation of wound edges, the color of the wound and surrounding area, and signs of dehiscence. Assess for the presence of sutures, staples, or adhesive closure strips. Note the stage of the healing process and characteristics of any drainage. Assess the surrounding skin for color, temperature, and edema, ecchymosis, or maceration. Ibrahim Ayasreh RN, PhD, 2021 Implementation Perform hand hygiene and put on PPE, if indicated. Identify the patient. Assemble equipment on overbed table within reach. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why you are going to do it. Place a waste receptacle or bag at a convenient location for use during the procedure. Adjust the bed to a comfortable working height, usually elbow height of the caregiver. Assist the patient to a comfortable position that provides easy access to the wound area. Use the bath blanket to cover any exposed area other than the wound. Place a waterproof pad under the wound site.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Put on clean, disposable gloves and loosen tape on the old dressings. If necessary, use an adhesive remover to help get the tape off. Carefully remove the soiled dressings. If there is resistance, use a silicone- based adhesive remover to help remove the tape. If any part of the dressing sticks to the underlying skin, use small amounts of sterile saline to help loosen and remove it. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle. Remove your gloves and dispose of them in an appropriate waste receptacle Ibrahim Ayasreh RN, PhD, 2021  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Implementation Inspect the wound site for size, appearance, and drainage. Assess if any pain is present. Check the status of sutures, adhesive closure strips, staples, and drains or tubes, if present. Using sterile technique, prepare a sterile work area and open the needed supplies. Open the sterile cleaning solution. Depending on the amount of cleaning needed, the solution might be poured directly over gauze sponges over a container for small cleaning jobs, or into a basin for more complex or larger cleaning. Put on sterile gloves. Alternately, clean gloves (clean technique) may be used when cleaning a chronic wound or pressure ulcer.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Implementation Clean the wound. Clean the wound from top to bottom and from the center to the outside. Following this pattern, use new gauze for each wipe, placing the used gauze in the waste receptacle. Alternately, spray the wound from top to bottom with a commercially prepared wound cleanser. Once the wound is cleaned, dry the area using a gauze sponge in the same manner. Apply ointment or perform other treatments, as ordered. Apply a layer of dry, sterile dressing over the wound. Forceps may be used to apply the dressing.  Ibrahim Ayasreh RN, PhD, 2021 Ibrahim Ayasreh RN, PhD, 2021 Implementation Apply a surgical or abdominal pad (ABD) over the gauze at the site of the outermost layer of the dressing, as necessary.  Ibrahim Ayasreh RN, PhD, 2021 Implementation Remove and discard gloves. Apply tape, or roller gauze to secure the dressings. Alternately, many commercial wound products are self-adhesive and do not require additional tape. After securing the dressing, label it with date and time. Remove all remaining equipment; place the patient in a comfo