*Perform hand hygiene, knock on door, floor assessment.
“There’s no cords or water on the floor that I might trip on.”
*Put on gloves and introduce yourself.
“Hi, my names Faye and I will be your student nurse today.”
*Perform level of consciousness.
“Can I get your first and last name, your date of birth, where are you, and who’s the president?”
*Check wrist band. Patient is awake, alert, and oriented.
*Jevity feeding should be turned off 30 minutes before and after med administration.
“I will be giving you your medications, but first I need to perform an assessment. I will be
assessing your heart, breathing, and abdomen. Is that okay? Is it okay if I touch you?”
“Are you feeling any pain? On a scale of 1 to 10 how bad is your pain? Do you have an
allergy’s?”
“Okay, first I’m going to listen to your heart sounds. Can I pull down your gown?”
*Perform inspection of the chest. Auscultate heart sounds.
“Aortic is 2nd ics, right sternal border; pulmonic is 2nd ics, left sternal border; erb’s point is 3rd
ics, left sternal border; tricuspid is 4th ics, left sternal border; and apical is 5th ics,
midclavicular.”
“Now, I’ll listen to the lungs. Bronchial is the trachea, vesicular is 6th intercostal space, mid
axillary line, and bronchiovesicular is 2nd and 4th intercostal space.”
“Okay, now I will be inspecting the abdomen. I see the peg tube, there’s no drainage and the
dressing is dry; it’s intact. I see no redness or swelling around the area.”
“I’m going to listen to your stomach, okay. I will listen in all four quadrants, starting from the
lower right for 1 minute each. Less than 5 sounds is hypoactive and more than 35 is
hyperactive.”
“I’m going to press against your stomach, let me know where you feel pain.”
“Okay, I’m finished with my assessment and I’m going to get your medications. I will be right
back, if you need anything you can ring your bed alarm.”
*Lower the bed. Perform hand hygiene.
Next step, 3 Checks.
*Mar to doctors order. If it’s on the doctors order but not on the mar, add to mar and initial with
time/date. If it’s on the mar but not in the doctors order, cross it out on the mar and initial with
time/date.
*Mar to medication. Grab medication from cart. Sit down and solve math problems, ask about
pcaves (compatibility or contraindications, can the insulin’s be combined, are the IV bags
compatible, action of the med, labs and vitals).
*Check expiration date on meds and IV bags. Change primary every 72 hrs, piggy back every 24
*After finishing math, write labels first bad then grab supplies (needles, syringes, IV bags,
tubing, cups, alcohol, labels).
*For peg ask if patient is on fluid restriction.
*Put on gloves and draw medications. Make sure to wipe the vials.
*Prepare central line flush.
“For the flush I will need, 3 10mL syringes filled with saline.
*After drawing meds, remove gloves.
*Mar to patient. Knock on door and enter patients room and perform hand hygiene. Raise bed.
*Make sure CVC clamp is closed before taking off cap. Wipe port, connect the syringe, and
unclamp.
“First, I will flush the central line with 10cc of saline fir each. I will aspirate for blood return
(you want to see blood, in lower 1/3 of superior vena cava).
*Ask how long will push (1 mL/minute), clamp and remove syringe. And I will do the same for
the other 2 lines.
*Ask about the compatibility with the fluids and medications. Connect line to central line and set
drip rate.
“Next, I will be going you your injections.”
*Explain the med you will be giving, it’s actions, and side affects.
*Give IM injections.
*When injecting tell patient they will feel a pinch.
*Verbalize the sites. Vastus lateralis (left hand on the greater trochanter, right hand on lateral
condyle of the knee. In middle 1/3, making a diamond and the injection is in the middle).
Ventrogluteal (palm on greater trochanter, thumb facing pubic symphysis, index finger facing the
anterior superior iliac spine, middle finger facing the posterior superior iliac spine and injection
site is between the index and middle finger). Deltoid (feel the acromion process with no
dominant hand, index finger on acromion process with 3 fingers, make a V and injection site is in
the middle)
*Aspirate vastus lateralis and ventrogluteal (don’t want blood), DO NOT ASPIRATE deltoid. 90
degrees for all
*Next give subcutaneous injections. 45 or 90 degrees. DO NOT ASPIRATE.
*Insulin check blood glucose, ask about last site, make sure there’s food. Verbalize that you
would monitor patient for signs of hypoglycemia.
“Next, I will be giving your medications through the peg tube.”
*Materials: chuck, syringe, kidney basin
*Clean port with alcohol.
*Draw 20 cc of air and push into peg.
“I will be checking for residual (gastric content). Ask professor if there’s any residual. If less
than 250mL put it back, if it’s more take it out and document in in output.
*Check correct placement of valve, make sure it’s opened or closed.
*Begin to administer meds. Make sure you close valve after putting meds each time.
“I take out the syringe and make sure the valve is open. First, I will flush with 30mL, 30mL of
med, 2nd flush is 15mL, 30mL of med, 3rd flush is 15mL, 30mL of med, final flush is 30mL.
Close valve.
*Stay with patient and exam for any reactions.
“I have administered all medications, I lower the bed and clean my table. I perform hand hygiene
and ask the patient if they need anything before I go.”
