Level 4 Modules For Nursing Skills Audit

FAR EASTERN UNIVERSITY
Institute of Nursing
MODULE 1: ASEPTIC TECHNIQUE
Learning Outcomes:
After the lecture-demonstration, the student will develop skills needed in the OR
and appreciate the importance of asepsis as a measure to preserve and promote
health. Specifically, the students will be able to:
1. Describe skin preparation for different surgical procedures
2. Demonstrate sterile procedures such as:
a. Surgical Hand scrub
b. Gloving Technique
c. Draping of instrument table and back table
d. Handling of sterile supplies
e. Sterile transfer technique
3. Appreciate the roles of Scrub nurse and Circulating nurse
Surgical Asepsis
Asepsis refers to the absence of infectious material or infection.
Surgical asepsis is the absence of all microorganisms within any type of invasive
procedure. Sterile technique is a set of specific practices and procedures performed to
make equipment and areas free from all microorganisms and to maintain that sterility
(BC Centre for Disease Control, 2010).
In the literature, surgical asepsis and sterile technique are commonly used
interchangeably, but they mean different things (Kennedy, 2013). Principles of sterile
technique help control and prevent infection, prevent the transmission of all
microorganisms in a given area, and include all techniques that are practised to
maintain sterility.
-1-
Sterile technique is most commonly practised in operating rooms, labour and delivery
rooms, and special procedures or diagnostic areas. It is also used when performing a
sterile procedure at the bedside, such as inserting devices into sterile areas of the body
or cavities (e.g., insertion of chest tube, central venous line, or indwelling urinary
catheter). In health care, sterile technique is always used when the integrity of the skin
is accessed, impaired, or broken (e.g., burns or surgical incisions). Sterile technique
may include the use of sterile equipment, sterile gowns, and gloves (Perry et al., 2014).
Sterile technique is essential to help prevent surgical site infections (SSI), an

unintended and oftentimes preventable complication arising from surgery. SSI is defined
as an “infection that occurs after surgery in the area of surgery” (CDC, 2010, p. 2).
Preventing and reducing SSI are the most important reasons for using sterile technique
during invasive procedures and surgeries.
Principles of Surgical Asepsis

All personnel involved in an aseptic procedure are required to follow the principles and
practice set forth by the Association of periOperative Registered Nurses (AORN). These
principles must be strictly applied when performing any aseptic procedures, when
assisting with aseptic procedures, and when intervening when the principles of surgical
asepsis are breached. It is the responsibility of all health care workers to speak up and
protect all patients from infection. See table below for the principles of sterile technique.
Principles of Sterile Technique
Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
• Hand hygiene is a priority before any aseptic procedure.
• When performing a procedure, ensure the patient understands how to prevent

contamination of equipment and knows to refrain from sudden movements or touching,
laughing, sneezing, or talking over the sterile field.
-2-
• Choose appropriate PPE to decrease the transmission of microorganisms from patients

to health care worker.
• Review hospital procedures and requirements for sterile technique prior to initiating any
invasive procedure.
• Health care providers who are ill should avoid invasive procedures or, if they can’t
avoid them, should double mask.
Steps Additional Information
Commercially packaged sterile supplies are marked

as sterile; other packaging will be identified as sterile
according to agency policy.
Check packages for sterility by assessing intactness,

1. All objects used in a sterile field
dryness, and expiry date prior to use.
must be sterile.
Any torn, previously opened, or wet packaging, or
packaging that has been dropped on the floor, is
considered non-sterile and may not be used in the
sterile field.
Sterile objects must only be touched by sterile

equipment or sterile gloves.
Whenever the sterility of an object is questionable,

2. A sterile object becomes non-sterile consider it non-sterile.
when touched by a non-sterile object. Fluid flows in the direction of gravity. Keep the tips of
forceps down during a sterile procedure to prevent
fluid travelling over entire forceps and potentially
contaminating the sterile field.
3. Sterile items that are below the waist Keep all sterile equipment and sterile gloves above
level, or items held below waist level, waist level.
are considered to be non-sterile. Table drapes are only sterile at waist level.
4. Sterile fields must always be kept in Sterile fields must always be kept in sight throughout
sight to be considered sterile. entire sterile procedure.
-3-
Never turn your back on the sterile field as sterility

cannot be guaranteed.
Set up sterile trays as close to the time of use as

possible.
Stay organized and complete procedures as soon as

5. When opening sterile equipment and
possible.
adding supplies to a sterile field, take
Place large items on the sterile field using sterile
care to avoid contamination.
gloves or sterile transfer forceps.
Sterile objects can become non-sterile by prolonged

exposure to airborne microorganisms.
6. Any puncture, moisture, or tear that

passes through a sterile barrier must Keep sterile surface dry and replace if wet or torn.
be considered contaminated.
7. Once a sterile field is set up, the

Place all objects inside the sterile field and away from
border of one inch at the edge of the
the one-inch border.
sterile drape is considered non-sterile.
8. If there is any doubt about the

Known sterility must be maintained throughout any
sterility of an object, it is considered
procedure.
non-sterile.
The front of the sterile gown is sterile between the

shoulders and the waist, and from the sleeves to two
inches below the elbow.
9. Sterile persons or sterile objects Non-sterile items should not cross over the sterile
may only contact sterile areas; non- field. For example, a non-sterile person should not
sterile persons or items contact only reach over a sterile field.
non-sterile areas. When opening sterile equipment, follow best practice
for adding supplies to a sterile field to avoid
contamination.
Do not place non-sterile items in the sterile field.
-4-
Do not sneeze, cough, laugh, or talk over the sterile

field.
Maintain a safe space or margin of safety between

sterile and non-sterile objects and areas.
Refrain from reaching over the sterile field.

10. Movement around and in the sterile
Keep operating room (OR) traffic to a minimum, and
field must not compromise or
keep doors closed.
contaminate the sterile field.
Keep hair tied back.
When pouring sterile solutions, only the lip and inner

cap of the pouring container is considered sterile. The
pouring container must not touch any part of the
sterile field. Avoid splashes.
Data source: Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry et al., 2014;
Rothrock, 2014
COVID 19: Considerations for Optimum Healthcare workers’ Protection Before,

During, and After Operation
There are presently increasing amounts of information concerning protecting the health
care worker, including in the operation room. This section brings together the latest
information, data, and recommendations for personnel in the operating room, as well as
how to minimize risk of COVID infection afterwards.
In this section, the following issues are addressed.

1. Use of Personal Protective Equipment (in the operating room, including appropriate
donning/doffing of the PPE)
2. Intubation Risks
3. Specific Operative Risk Issues
4. After operation/leaving the OR, and leaving the facility
-5-
1. Use of Personal Protective Equipment

• Use of personal protective equipment is recommended by the Centers for
Disease Control for every operative procedure performed on a patient with
confirmed COVID-19 infection or a patient where there is suspicion for infection.
• N95 respirators or respirators that offer a higher level of protection should be
used when performing or present for an aerosol-generating procedure (e.g. OR
patient intubation) in COVID19 or suspected infected patient.
• Disposable respirators and facemasks should be removed and discarded
appropriately in accordance with local policy.
• Perform hand hygiene after discarding the respirator or facemask. • CDC videos
for donning and doffing personal protective N-95 masks (donning and doffing).
The full video can be found at this CDC website.
• Fit testing is paramount to ensure proper mask fit.
• There is a distinct possibility that personal protective equipment, including
acceptable masks (such as the N95 mask) may be in short supply. Healthcare
institutions are encouraged to develop protocols for preserving supplies of masks
and protective equipment. The CDC has outlined strategies for optimizing the
supply of facemasks.
-6-
2. Intubation Risks
• Aerosolization and droplet transmission of the COVID-19 virus are important
hazards for surgical personnel.
• Aerosolization and droplet transmission hazard increases with procedures such
as endotracheal intubation, tracheostomy, gastrointestinal endoscopy and during
the evacuation of pneumoperitoneum and aspiration of body fluids during
laparoscopic procedures.
• Surgeons and personnel not needed for intubation should remain outside the
operating room until anesthesia induction and intubation are completed for
patients with or suspected of having COVID-19 infection.
-7-
• Negative pressure operating rooms and/or anterooms when available are

recommended. A review article that presented data on the use and effectiveness
of negative pressure operating rooms is referenced here: Chow TT, Yang XY.
Ventilation performance in operating theatres against airborne infection: review of
research activities and practical guidance. Journal of Hospital Infection.
2004;56(2):85-92.
• A recent study in the New England Journal of Medicine shows how long COVID-
19 might remain infectious on different surfaces (e.g. cardboard 1 day, plastic 3-4
days).
• Appropriate PPEs need to be used per local policy - this article provides a useful
discussion of overarching management in the OR of a COVID-19 infected
patient, and also the intra-operative protocol used in Singapore.
3. Specific Operative Risk Issues

• Have minimum number of personnel in the operating room, including during
intubation, as well as throughout. No visitors or observers.
• Use smoke evacuator when electrocautery is used.
• Consider avoiding laparoscopy
• Tracheostomy considerations are important because of the high risk for
aerosolization. A guide for tracheostomy is available here.
4a. After operation/Recovery

• If transport of a patient with or suspected to have COVID-19 infection to an
outside recovery area or intensive care unit is necessary, handoff to aa minimum
number of transport personnel who are waiting outside the operating room
should be considered. Personnel should wear personal protective equipment as
recommended by the CDC. Personal protective equipment should be not be the
same as worn during the procedure.
• Recommendations for surgeon protection before and after separating from a
patient with or suspected of having COVID-19 infection vary from institution to
institution. We reached out to surgeons at four academic medical centers to
-8-
obtain their perspectives on behavior following separation from the patient.

Selections from these perspectives are presented here
• Remove clothes worn from home and keep in garment bag.
• Wear scrub clothes after arrival at hospital
• After separating from the patient remove scrub clothes; consider
showering before changing into a clean scrub suit or home clothes
• Wash hands frequently and maintain safe social distancing
4b. Going home – what should be done to keep your family safe
• Healthcare institutions and systems may make hotel accommodations available
for healthcare workers who cannot or prefer not to go home following patient care
activities.
• Be alert to the fact that viral contamination of surfaces is a known means of
transmission of infection.
• Keep hand sanitizer and/or disposable gloves for use of ATM, vending machines,
gasoline pumps, and transfer of items at the time of purchases.
• Clean your cell phone frequently before, during, and after patient care activities.
Cell phones may be kept in a Ziploc bag during work activities. The phone can be
used while in the bag
• Consider removing clothes and washing them upon arrival home.
• Consider reducing physical contact with family members and wash hands
frequently. • Clean hard surfaces at home with an effective disinfectant solution
(e.g. 60% alcohol).
Disclaimer: These guidelines are meant to serve patients based on estimates of risk for
average patients (in terms of clinical condition, patient health, hospital resource
availability) associated with each strategy. - These should not be considered rigid
guidelines and are not intended to supplant clinical judgement or the development of
consensus regarding institutional approaches to treatment. There is a great deal of
uncertainty around this evolving pandemic and information may change rapidly. - It is
possible that the strategies outlined in this document could be replaced as our
-9-
understanding of unique challenges that COVID-19 poses within each country, state,
and healthcare environment evolves.
Surgical Hand Scrub

Skin is a major source of microorganisms and a major source of contamination in the
OR setting (CDC, 2010). Since skin cannot be sterilized, members of the surgical team
must wear sterile gloves. The purpose of the surgical hand scrub is to significantly
reduce the number of skin bacteria found on the hands and arms of the OR staff
(Kennedy, 2013).
A surgical hand scrub is an antiseptic surgical scrub or antiseptic hand rub that is
performed prior to donning surgical attire (Perry et al., 2014) and lasts two to five
minutes, depending on the product used and hospital policy. Studies have shown that
skin bacteria rapidly multiply under surgical gloves if hands are not washed with an
antimicrobial soap, whereas a surgical hand scrub will inhibit growth of bacteria under
gloved hands (Kennedy, 2013).
Types of surgical hand scrubs

Surgical hand scrub techniques and supplies to clean hands will vary among health
care agencies. Most protocols will require a microbial soap-and-water, three- to five-
minute hand scrub procedure. Some agencies may use an approved waterless hand
scrub product.
- 10 -
SURGICAL HANDWASHING
• All personnel entering the operating room (OR) or a specific sterile procedure must
perform a surgical hand scrub.
• Hands must be free from rings, watches, and bracelets. Nails should be free from any
nail enhancements, artificial extenders, acrylics, wraps, and tips. Nail polish must be
free from chips or cracks. Research shows that the amount of bacteria is nine times
higher on rings and on the skin beneath the fingernails.
• All skin on the forearm and hands (including cuticles) should be free from open lesions
and breaks in skin integrity. Any allergies to the cleansing products should be reported
to the manager.
• If hands touch anything during cleaning, the entire procedure must be started from the
beginning.
Steps Rationale
Jewellery harbours microorganisms.
1. Remove all jewellery.
Remove jewellery
2. No artificial nails, extenders, or chipped nail Artificial nails, extenders, and chipped nail
polish should be worn in the OR. polish can harbour microorganisms.
3. Inspect hands for sores or abrasions; cover
Open sores can harbour microorganisms.
or report to supervisor as required.
4. Ensure sleeves are at least two to three This step prevents sleeves from becoming
inches above the elbows. moist.
5. Clean hands with Antibacterial hand rub Hand hygiene is recommended by the
(ABHR) or soap and water to remove visible Association of periOperative Registered
debris. Nurses (AORN).
- 11 -
Hand hygiene with ABHR

Regulate the temperature of the water. Warm
water is recommended to prevent drying out of
hands.
6. Turns tap on, regulate the flow and

temperature of water.
Wet hands
7. Pretears package containing brush; lay the
brush on the back of the scrub sink
8. Wets hands and arms for an initial prescrub
wash. Use about 5 ml (1 pump) of surgical A good amount of soap is required to create
detergent, work up a heavy lather, up to three lather for a three- to five-minute scrub.
inches above the elbow for 30 secs..
9. Rinses hands and arms thoroughly, allow
the water to run from the elbows to the hands.
10. Removes the sterile brush and nail stick,

Nail files work more effectively than a nail
moisten brush and work up a lather. Soap
brush. Clean the subungal area (under the
fingertips and clean the spaces under the
fingernails) with a nail file. Nail brushes are not
fingernails of both hands using the nail stick
recommended as they may damage the skin
under running water for 15 secs. in all; discard
around the nail.
nail stick.
11. Lathers fingertips with sponge-side of

brush; Using bristle side of brush, scrub the
spaces under the fingernails of one hand 30
circular strokes or 15 secs. each hand using
straight strokes going away from you.
12. Lathers digits; Scrub 20 strokes on all four
sides of each finger for 1 minute beginning
with the thumb or little finger of one hand.
- 12 -
Scrub one hand and arm completely before

moving on to the other hand and arm. Using
straight strokes going away from you
13. Lathers palm, back of hand, heel of hand,
& space between thumb and index finger.
Scrub 20 circular strokes on each surface.
14. Readies to scrub the forearm. Divides arm
in three inch increments. Uses the sponge-
side of the brush lengthwise to apply soap
around wrist. Scrubs 5 circular strokes on
each of four sides; moves up the forearm—
lather, then scrubs up to two inches above the
elbow
15. Runs brush under water and add soap
anytime.
16. Scrub the arms, using an up-and-down

Keeping hands above the wrist allows for the
motion, keeping hands above the elbows at all
microorganisms to slide off the hands into the
times. Wash each side of the arm from wrist
sink.
to elbow for one minute.
17. Repeat the entire process or steps 6 Use an equal amount of time to wash each
through 9 with the other hand and forearm. hand.
18. With hands raised, Rinses hands and
arms without retracing nor contaminating. This step allows for all the soap to be rinsed off
Turns off tap. let the water drip down from the from cleanest to dirtiest area.
fingertips to the elbow.
19. Proceed into the operating room (keep
hands above the waist), and dry arms using a This step prevents contamination of the hands
sterile towel, starting at the fingertips and and adheres to the principles of sterile
working down toward the forearms using a technique.
dabbing motion.
Data source: ATI, 2015a; Bartlett, Pollard, Bowker, & Bannister, 2002; Kennedy, 2013; WHO,
2009a
----------PROCEDURE WILL CONTINUE after the discussion on the OR environment----
Operating Room Environment
The operating room (OR) is a sterile, organized environment. As a health care provider,
you may be required to enter the OR during a surgical procedure or to set up before a
surgical procedure. It is important to understand how to enter an OR area and how the
OR area functions to maintain a sterile environment.
- 13 -
Members of the surgical team work hard to coordinate their efforts to ensure the safety
and care of their patients. The surgical team is in charge of the OR and makes
decisions regarding patient care procedures. The OR environment has sterile and non-
sterile areas, as well as sterile and non-sterile personnel. It is important to know who is
sterile and who not, and which areas in the OR are sterile or non-sterile.
Sterile OR Personnel
• Surgeon
• Surgical assistant
• Scrub nurse
Non-sterile OR Personnel
• Anesthesiologist
• Circulating nurse
• Technologist, student, or observer
There are specific requirements for all health care professionals entering the OR to
minimize the spread of microorganisms and maintain sterility of the OR environment.
Prior to entering the OR, show your hospital-issued ID and inform the person in charge
of the purpose of your visit. Refer to Checklist 10 for the specific steps to take before
entering an OR.
Checklist: Entering the OR

This step prevents the need to unnecessarily leave the

1. Bring all required supplies to the
restricted area.
OR. Sterilize or disinfect them as
Movement in the OR should be kept to a minimum to
required.
avoid contamination of sterile items or persons.
2. State the purpose of your visit to This step allows for clear communication with the
OR personnel and show your ID. health care team.
- 14 -
3. Artificial nails should not be worn,

Artificial nails, extenders, and chipped nail polish
and nail polish should be fresh (not
harbour more microorganisms than hands and can
more than four days old) and not
potentially contaminate the sterile area.
chipped.
4. Remove all jewellery. Wedding

Jewellery harbours additional microorganisms and
bands may be permitted under
must be removed prior to a surgical hand scrub.
agency policy.
5. Don surgical attire (top and

bottom). Surgical attire must be worn Surgical attire must be worn only in the surgical area to
only in the surgical area. Tuck top into avoid contamination outside the surgical area.
pants.
Shoe covers will protect work shoes from accidental

6. Cover shoes according to agency
blood or body fluid spills in the OR. Shoe covers must
policy.
not be worn outside the OR area.
Surgical hand scrubs reduce the bacterial count on

7. Perform a surgical hand scrub
hands prior to applying sterile gloves. Hands are kept
according to agency policy.
above waist at all times.
Mask must cover nose, mouth, and chin for a proper

seal. Mask should be changed if it becomes wet or
soiled.
A surgical mask or N95 mask may be required,
depending on whether the patient is on additional
8. Prior to entering the restricted or precautions.
semi-restricted area: Knowing what area is sterile/non-sterile will prevent
1. Apply mask. accidental contamination of sterile fields and delays in
surgery.
2. Apply head covering to cover
earrings, beard, and Sterile persons/area
sideburns. The sterile field should be created as close as possible
3. Once in the OR, introduce to the time of use. Covering sterile fields is not
yourself to the surgical staff recommended.
and inquire about the sterile Sterile areas should be continuously kept in view. An
area and non-sterile areas. unguarded sterile field is considered contaminated.
Sterile persons should keep well within the sterile area.
Sterile persons should pass each other back to back or
front to front. A sterile person should face a sterile area
to pass it and stay within the sterile field.
Non-sterile person/area
- 15 -
A non-sterile person should stay at least one foot away

from the sterile field, and face the sterile field when
passing it.
A non-sterile person should not walk between two
sterile fields or reach over the sterile field.
Data source: Kennedy, 2013; ORNAC, 2011; Perry et al., 2014; Rothrock, 2014
Continuation of the Procedure – GOWNING

GOWNING
20. Slightly bends forward, reaches down to the sterile package and lifts the folded gown
directly upward. Steps back away from the table, into a clean area to provide a wide
margin of safety while unfolding the gown halfway.
21. Unfolds the gown while holding the folded neck part of the gown. Exposes the hemline
portion. Dries hands and arms with this small portion with a blotting, rotating motion.
22. Works from fingertips, the arms, elbow and the forearm; DOES NOT retrace any area.
23. Grasps the other side of the neck part of the gown with the other hand and dries the
other arm with the same manner as the other arm. Uses each side of the folded gown in
drying each hand and arm.
Sterile gloves are gloves that are free from all microorganisms. They are required for
any invasive procedure and when contact with any sterile site, tissue, or body cavity is
expected (PIDAC, 2012). Sterile gloves help prevent surgical site infections and reduce
the risk of exposure to blood and body fluid pathogens for the health care worker.
Studies have shown that 18% to 35% of all sterile gloves have tiny holes after surgery,
and up to 80% of the tiny puncture sites go unnoticed by the surgeon (Kennedy, 2013).
Double gloving is known to reduce the risk of exposure and has become common
practice, but does not reduce the risk of cross-contamination after surgery (Kennedy,
2013).
- 16 -
GLOVING
1. Opens the inner package containing the gloves and pick up one glove by the folded cuff
edge with the sleeve-covered hand
2. Puts the glove on the opposite gown sleeve, palm down, with the glove’s fingers pointing
toward shoulder. The palm of the hand inside the gown sleeve must be facing upward
toward the palm of the glove.
3. Puts the glove's rolled cuff edge at the seam that connects the sleeve to the gown cuff.
Grasps the bottom rolled cuff edge of the glove with the thumb and index finger
4. While holding the glove's cuff edge with one hand, grasps the uppermost edge of the
glove's cuff with the opposite hand. Does not expose the bare fingers while doing this.
5. Continues to grasp the glove; stretches the cuff of the glove over the hand
6. Uses the opposite sleeve- covered hand, grasps both the glove cuff and sleeve cuff seam
and pulls the glove onto the hand. Pulls any excessive amount of gown sleeve from
underneath the cuff of the glove.
7. Using the hand that is now gloved, puts on the second glove in the same manner. Adjusts
the fingers of the glove as necessary so that they fit snugly.
OFFERING THE GOWN
1. Picks up the gown directly from the table or receive it from the circulating nurse.
2. Unfolds the gown slowly and serves the hemline portion to the surgeon. Continues
unfolding the gown while the surgeon is drying his hands and arms.
3. When serving the gown, nurse’s gloved hands should come in contact with the right-side
portion of the gown under the protecting cuff made.
4. Shows the opening and armholes to the surgeon. As soon as the surgeon inserts his
hands through the armholes, pulls the gown over the surgeon’s shoulders.
SERVING THE GLOVES
1. Grasps the right glove firmly at waist level. Keeping thumbs extended and covered by the
glove cuff, stretches the cuff so that the doctor can introduce his hand without touching
nurse’s gloves.
2. While stretching the glove open, stand with one foot forward and one foot to the rear.
Offers the right glove first
3. Repeats the technique above for the left hand.
4. Applies aseptic technique all throughout the procedures
- 17 -
NURSING SKILLS AUDIT
Surgical Handwashing / Gowning / Gloving
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
DIRECTION: Please check the appropriate box if the student demonstrated competency
Yes No
PREPARATION
1. Assembles articles needed at the bedside
2. Performs hand hygiene
SURGICAL HANDWASHING
1. Turns tap on, regulate the flow and temperature of water.
2. Pretears package containing brush; lay the brush on the back of
the scrub sink
3. Wets hands and arms for an initial prescrub wash. Use about 5 ml
(1 pump) of surgical detergent, work up a heavy lather, up to three
inches above the elbow for 30 secs.
4. Rinses hands and arms thoroughly, allow the water to run from the
elbows to the hands
5. Removes the sterile brush and nail stick, moisten brush and work
up a lather. Soap fingertips and clean the spaces under the
fingernails of both hands using the nail stick under running water
for 15 secs. in all.; discard nail stick.
6. Lathers fingertips with sponge-side of brush; Using bristle side of
brush, scrub the spaces under the fingernails of one hand 30
circular strokes or 15 secs. each hand using straight strokes going
away from you.
7. Lathers digits; Scrub 20 strokes on all four sides of each finger for
1-minute beginning with the thumb or little finger of one hand.
Scrub one hand and arm completely before moving on to the other
hand and arm. Using straight strokes going away from you
8. Lathers palm, back of hand, heel of hand, & space between thumb
and index finger. Scrub 20 circular strokes on each surface.
9. Readies to scrub the forearm. Divides arm in three-inch
increments. Uses the sponge-side of the brush lengthwise to apply
soap around wrist. Scrubs 5 circular strokes on each of four sides;
moves up the forearm—lather, then scrubs up to two inches above
the elbow
10. Runs brush under water and add soap anytime.
- 18 -
11. Repeats steps (6) through (9) above for the other arm. Discards
brush
12. Rinses hands and arms without retracing nor contaminating
13. Turns off tap
14. Allows water to drip from the elbows before entering the operating
room
GOWNING
15. Slightly bends forward, reaches down to the sterile package and
lifts the folded gown directly upward. Steps back away from the
table, into a clean area to provide a wide margin of safety while
unfolding the gown halfway.
16. Unfolds the gown while holding the folded neck part of the gown.
Exposes the hemline portion. Dries hands and arms with this
small portion with a blotting, rotating motion.
17. Works from fingertips, the arms, elbow and the forearm; DOES
NOT retrace any area.
18. Grasps the other side of the neck part of the gown with the other
hand and dries the other arm with the same manner as the other
arm. Uses each side of the folded gown in drying each hand and
arm.
GLOVING
1. Opens the inner package containing the gloves and pick up one
glove by the folded cuff edge with the sleeve-covered hand
2. Puts the glove on the opposite gown sleeve, palm down, with the
glove’s fingers pointing toward shoulder. The palm of the hand
inside the gown sleeve must be facing upward toward the palm of
the glove.
3. Puts the glove's rolled cuff edge at the seam that connects the
sleeve to the gown cuff. Grasps the bottom rolled cuff edge of the
glove with the thumb and index finger
4. While holding the glove's cuff edge with one hand, grasps the
uppermost edge of the glove's cuff with the opposite hand. Does
not expose the bare fingers while doing this.
5. Continues to grasp the glove; stretches the cuff of the glove over
the hand
6. Uses the opposite sleeve- covered hand, grasps both the glove
cuff and sleeve cuff seam and pulls the glove onto the hand. Pulls
any excessive amount of gown sleeve from underneath the cuff of
the glove.
7. Using the hand that is now gloved, puts on the second glove in the
same manner. Adjusts the fingers of the glove as necessary so
that they fit snugly.
- 19 -
OFFERING THE GOWN

1. Picks up the gown directly from the table or receive it from the
circulating nurse.
2. Unfolds the gown slowly and serves the hemline portion to the
surgeon. Continues unfolding the gown while the surgeon is drying
his hands and arms.
3. When serving the gown, nurse’s gloved hands should come in
contact with the right-side portion of the gown under the protecting
cuff made.
4. Shows the opening and armholes to the surgeon. As soon as the
surgeon inserts his hands through the armholes, pulls the gown
over the surgeon’s shoulders.
SERVING THE GLOVES
1. Grasps the right glove firmly at waist level. Keeping thumbs
extended and covered by the glove cuff, stretches the cuff so that
the doctor can introduce his hand without touching nurse’s gloves.
2. While stretching the glove open, stand with one foot forward and
one foot to the rear. Offers the right glove first
3. Repeats the technique above for the left hand.
4. Applies aseptic technique all throughout the procedures
Score = (No. of YES) / 35 x100 = _____%
___________________________ ___________________________
Signature of student Name & Signature of faculty
- 20 -
MODULE 2a: INTRAVENOUS INSERTION
Learning Objectives:
After the learning session, the students will be able to:
1. Recognize the risks and benefits of starting a peripheral IV
2. Describe the steps for peripheral IV insertion
3. Gather the appropriate supplies and equipment for peripheral IV insertion
4. Select the appropriate type and size of IV catheter based on reason for IV
therapy
5. Identify potential sites for peripheral IV insertion (e.g. cephalic and basilic veins in
the forearm, veins in the dorsum on the hand) and describe strategies for finding
veins
6. Assess peripheral IV site for complications and identify nursing actions related to
complications (e.g. phlebitis, infiltration, extravasation, infection)
7. Discontinue peripheral IV and inspect catheter and site
8. Recognize components for appropriate documentation of IV therapy
I. Materials/Equipment
1. Dummy IV arm
2. Prescribed IV solution (1,000 ml in adult patients, 500 ml in pediatric patients)
3. Macro-drip or micro-drip infusion set (Burette set)
4. Needleless systems (extension set with stopcock or needleless connector)
5. IV catheter or cannula (18G, blood transfusion and large volume infusions;
20G, routine infusion; 22G, elderly and clients with fragile, small veins; 24G,
pediatric client; 26G, neonate and infant)
6. IV tray
7. IV start pack or prep kit
a. Identification label
b. Tourniquet
c. Transpore tape, 36” x ¾”
d. Gauze sponges, 2” x 2”
- 21 -
e. Transparent dressing
f. Alcohol wipes
g. Povidone iodine prep
h. Syringe 5 ml, for flushing ports
i. Disposable gloves
8. Towel or disposable pad
9. IV splint or arm board, if needed
10. IV pole or stand
II. Concepts
Intravenous Therapy is the insertion of a needle or catheter into a vein based
on physician’s written prescription. The needle or catheter is attached to a sterile
tubing and fluid container to provide medicine and fluid. This procedure is to be
done only by a licensed professional nurse as per the Philippine nursing
law. Nursing students can take part in the actual procedure through
assisting the licensed nurse.
Purpose
1. To maintain/ correct dehydration in clients unable to tolerate sufficient volume
of oral fluids/ medicine
2. Parenteral nutrition
3. Administer drugs
4. Transfusion of blood or blood components
5. To provide a lifeline for rapidly needed medications or blood
Common Types of IV Solutions:

1. Colloids – contain proteins or other molecules of high molecular weight that
tend to remain intravascular for long periods of time. They exert osmotic
pressure (the pressure generated by the tendency of water to follow high
concentrations of molecules) thus, they draw interstitial and intracellular water
towards the intravascular fluid compartment. (e.g. Whole blood, plasma,
- 22 -
packed red blood cells, plasma substitutes like Dextran, Hespan, Plasma
Protein Fraction/ Plasmanate)
2. Crystalloids – solutions made by dissolving crystals into water. They are
good fluid replacers and are categorized by tonicity (the amount of particles
present in a solution)
a. Hypotonic – have less dissolved particles than plasma, good route for
medications but not a good choice as fluid replacers because it leaves
the vascular space. (i.e. D5W)
b. Hypertonic – have more dissolved particles than plasma and have
initial effect of drawing water from intracellular spaces to intravascular
space but once sugar content is metabolized, solution becomes
hypotonic (i.e. D5LR, D10W, 0.45% NaCl)
c. Isotonic - have roughly the same amount of dissolved particles as
plasma and good choice for fluid replacement (0.9% NaCl, Lactated
Ringers)
Sites for IVF Insertion (*Select a site distal to the heart and move proximally as
necessary)
- 23 -
Considerations in the Selection of the Site

1. Select a vein large enough to accommodate the size of the needle that will be
used.
2. Type of Solution (The more irritating to the veins the solution is, the larger the
vein should be chosen)
3. Client’s age (Pediatric and Geriatric clients tend to have fragile veins that has
the chances to bulge when handled inappropriately)
Container of Sterile Intravenous Solution
1. IV Solutions come in different volumes
a. 50mL
b. 150mL
c. 250mL
d. 500mL
e. 1000mL
2. Solution should be sterile and in proper condition

a. Check expiration date
b. No particulate matter in the solution
c. Check for any leaks indicative of contamination
Administration set
1. Macrodrip or macroset (10, 15, or 20 drops per ml of solution as drop factor)
2. Microset (60 drops per ml of solution as drop factor)
3. Volume-controlled set or Soluset
- 24 -
Parts of an Administration set
- 25 -
IV. Catheters by size and color
***Remember: IV catheter gauges (sizes) are different from hypodermic needles.

IV catheter gauges are by EVEN numbers and hypodermic needles are by ODD
numbers.
- 26 -
Butterfly or Wing-tipped needles
III. Procedure
The initiation of IV therapy is upon the written prescription of a licensed physician
which is checked for the:
1. Type of Solution
2. Flow rate
3. Amount of solution
4. Dose and frequency of medication to be incorporated
STEPS Rationale and Additional Information

1. Verify the written prescription To promote drug safety and avoid medication
for IV therapy errors
2. Check Dummy arm prepare IVF To save time and effort
and other things needed
3. Explain procedure to reassure To reassure the client and significant other
the patient and significant
others and observe the 12Rs in
drug administration
4. Perform hand hygiene before To prevent the spread of infection
and after the procedure
5. Wear gloves when only during To institute Contact precaution
venipuncture
6. Choose appropriate site, To ensure an effective delivery of intravenous
location, size, and condition of fluids and medications
the vein
7. Apply tourniquet 5 to 12 cm (2- To increase the visibility of the veins
6 in) above injection site
- 27 -
8. Check for radial pulse below To ensure that the application of the tourniquet
tourniquet does not impede the blood flow
9. Prepare site with effective To ensure asepsis during the procedure
topical antiseptic according to
institution’s policy (No touch
technique)
10. Use the appropriate IV cannula To ensure an effective delivery of intravenous
utilizing the correct technique fluids and medications
11. Insert catheter progressively
until backflow is visualized
12. Position the IV catheter parallel

to the skin
13. Hold stylet stationary and To ensure needle placement and avoid injury to
slowly advance the catheter the vein and surrounding tissues.
until the hub is 1mm to the
puncture site
- 28 -
14. Secure and apply the

appropriate taping technique
15. Connect the infusion tubing of

the prepared IVF aseptically
16. Tape a small loop of IV tubing This is to prevent accidental dislodgement of the
for additional anchoring. Apply IV catheter.
splint if needed.
17. Open the clamp and regulate To prevent fluid overload
the flow rate
18. Calibrate the IVF bottle and To effectively monitor the intravenous fluid input
regulate the flow of infusion to the patient.
19. Label on IV tape near the IV To have proper identification of the IV gauge
site to indicate DATE OF used.
INSERTION, TYPE and
GAUGE of IV catheter then
countersign
20. Label with plaster on the IV To prevent phlebitis
tubing to indicate the date when
to change the IV tubing
- 29 -
21. Observe and report any

untoward effect.
22. Discard sharps and waste To prevent needle stick injury and infection
according to Health Care
Waste Management
23. Document in the patient’s chart To promote patient safety and proper handover
and endorse to incoming shift.
- 30 -
Intravenous Cannula Insertion
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
STEPS YES NO
1. Verify the written prescription for IV therapy
2. Check Dummy arm prepare IVF and other things needed
3. Explain procedure to reassure the patient and significant others
and observe the 12Rs in drug administration
4. Perform hand hygiene before and after the procedure
5. Wear gloves when only during venipuncture
6. Choose appropriate site, location, size, and condition of the vein
7. Apply tourniquet 5 to 12 cm (2-6 in) above injection site
8. Check for radial pulse below tourniquet
9. Prepare site with effective topical antiseptic according to
institution’s policy (No touch technique)
10. Use the appropriate IV cannula utilizing the correct technique
11. Insert catheter progressively until backflow is visualized
12. Position the IV catheter parallel to the skin
13. Hold stylet stationary and slowly advance the catheter until the hub
is 1mm to the puncture site
14. Secure and apply the appropriate taping technique
15. Connect the infusion tubing of the prepared IVF aseptically
16. Tape a small loop of IV tubing for additional anchoring. Apply splint
if needed.
17. Open the clamp and regulate the flow rate
18. Calibrate the IVF bottle and regulate the flow of infusion
- 31 -
19. Label on IV tape near the IV site to indicate DATE OF INSERTION,

TYPE and GAUGE of IV catheter then countersign
20. Label with plaster on the IV tubing to indicate the date when to
change the IV tubing
21. Observe and report any untoward effect.
22. Discard sharps and waste according to Health Care Waste
Management
23. Document in the patient’s chart and endorse to incoming shift.
Score = (No. of YES) / 23 x 100 = ______%
___________________________ ___________________________
- 32 -
MODULE 2b: BLOOD TRANSFUSION
Learning Outcomes:
1. Identify the rationale for the selection of specific blood transfusion products including
whole blood, packed red blood cells, and platelets.
2. Describe pre-administration nursing priorities to assure safe administration of blood
products.
3. Identify potential pre-administration medications and rationale for use.
4. Identify six critical pieces of information that must be co-assessed by two licensed
personnel prior to blood administration.
5. Describe the essential steps with the administration of blood products including
tubing, filter, priming solution, and rate of administration.
6. Identify signs and symptoms of suspected acute and late transfusion reactions.
7. Describe immediate nursing action required for the patient with a suspected
hemolytic transfusion reaction.
Blood Transfusion is the introduction of whole blood or blood components (plasma,

serum, erythrocytes, or platelets) into the venous circulation.
Purposes:
1. To increase circulating blood volume as in shock due to haemorrhage
2. To increase red blood cell volume of haemoglobin content of the blood as in
anemia
3. To increase WBC content of the blood as in agranulocytosis and leukopenia
4. To increase the quantity of protein malnutrition, excessive loos of protein from
burns or vesicular skin diseases.
- 33 -
Equipment
1. IV tray
2. Compatible Blood Transufusion set (has a filter)
3. IV catheter appropriate for accommodating a blood transfusion (g20 and above)
4. Hypodermic needle (g19)
5. Micropore
6. Tourniquet
7. Blood product
8. 0.9% NaCl IV solution
9. IV stand
10. Gloves
Transfusion Products
- 34 -
ABO System Human blood is grouped according to the presence or absence of these
specific antigens. The two major antigens, A and B, form the basis of the ABO system.
It is important that the recipient not have antibodies to the donor’s RBCs. If this were to
occur, there could be a hypersensitivity reaction, which can vary from mild fever to
anaphylaxis with severe intravascular hemolysis. To prevent an acute hemolytic
transfusion reaction (AHTR), blood for transfusion must be of a compatible ABO blood
type. Patients should receive blood that matches their blood type. Type O (negative)
whole blood or RBCs may be used for any patient in an emergent situation and is
known as the “universal donor." Persons with Type AB + (positive) can receive blood
from any blood type and are considered the “universal recipient."
Transfusion Reactions
Blood transfusion reactions occur when the recipient's immune system launches a
response against a component of the transfused product. If the reaction occurs within
the first few minutes of the transfusion, it is termed an acute reaction. A reaction that
develops hours to days later is termed a delayed reaction. Late reactions may go
undetected for days, weeks, or even months, and generally occur more than 48 hours
after the transfusion.
If red blood cells are destroyed, the reaction is further classified as hemolytic; all other
types of reactions are non-hemolytic (Bielefeldt, 2009). Some reactions result from
infectious, chemical, or physical forces or human error during blood product preparation
or administration.
- 35 -
Types of Transfusion Reactions
Procedure
COMPETENCIES
STEP 1: PREPARATION
1 Checks the doctors order with the request
2 Checks patient’s name, serial number, blood type and Rh group, the blood donor number
and the expiration date of the blood
3 Observes the blood for abnormal color, clumping, gas bubbles and extraneous materials
4 Determines that consent for blood transfusion was signed and there is no known allergies
or previous adverse reactions to BT
5 Introduces self to patient and verifies patient’s name
6 Informs patient of the procedure and its importance
7 Does handwashing
8 Checks baseline vital signs
9 Assembles articles and equipment needed at the bedside
10 Positions patient accordingly
STEP 2: INITIATING BLOOD TRANSFUSION
1 Puts on gloves
2 Closes all the clamps
- 36 -
3 Inserts the piercing pin (spike) into a container of 0.9 percent saline solution using a
twisting motion
4 Hangs the IV container on the IV pole
5 Squeezes the drip chamber of the normal saline until it covers one-third of the drip
chamber
6 Expels any residual air in the tubing
7 Starts the saline solution
8 Prepares the blood bag by inverting the blood bag gently several times to mix the cells
with the plasma
9 Closes the roller clamp of the filter set and attaches a needle at the other end of the filter
set
10 Exposes the part of the blood bag by pulling back the tabs
11 Inserts the spike of the filter set into the blood bag
12 Opens the clamp of the blood bag to prime the tubing then closes the clamp
13 Closes the clamp on the IV saline solution
14 Inserts the needle of the blood bag to the Y- port of the saline IV bottle then opens the
clamp of the blood bag
15 Regulates the blood slowly for the first 10 minutes at 15 drops per min.
16 Observes the patient closely for the first 15 minutes for any reactions and take appropriate
nursing action
17 Re adjusts the flow rate of the blood transfusion after 10 min.
STEP 3: MAINTAINING A BLOOD TRANSFUSION
1 Monitors the patient’s vital signs every fifteen minutes for one hour after initiating the
transfusion
2 Assesses the patient including vital signs every 30 minutes for the next three hours until
blood transfusion is finished
3 Alerts senior nurse if there is any untoward reaction during the transfusion
STEP 4: TERMINATING A BLOOD TRANSFUSION
1 Puts on clean gloves
2 Clamps the blood tubing and disconnects needle from the Y-port
3 Opens the saline infusion clamp
4 Adjusts the saline drip to desired rate
5 Checks vital signs
STEP 5: AFTER CARE
1 Puts patient in a comfortable position
2 Discards the blood administration set according to agency policy
3 Puts needles in a labeled, puncture-resistant container
4 Follows agency protocol for appropriate disposal of the blood bag
5 Removes gloves and discards accordingly
STEP 6: DOCUMENTATION
1 Documents the procedure and all nursing assessment
a. Reason for the transfusion
- 37 -
b. Whether consent was signed

c. Time when blood transfusion was initiated
d. Type of blood transfused, amount, blood type, Rh factor, serial number, expiration
date and rate of flow
e. Any medication given prior to transfusion
f. Baseline vital signs
g. Any untoward reaction during the transfusion
h. Time when transfusion was terminated
- 38 -
Blood Transfusion
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
COMPETENCIES YES NO
STEP 1: PREPARATION
1. Checks the doctors order with the request

2. Checks patient’s name, serial number, blood type and Rh group, the
blood donor number and the expiration date of the blood
3. Observes the blood for abnormal color, clumping, gas bubbles and
extraneous materials
4. Determines that consent for blood transfusion was signed and there
is no known allergies or previous adverse reactions to BT
5. Introduces self to patient and verifies patient’s name
6. Informs patient of the procedure and its importance
7. Does handwashing
8. Checks baseline vital signs
9. Assembles articles and equipment needed at the bedside
10. Positions patient accordingly
STEP 2: INITIATING BLOOD TRANSFUSION
1. Puts on gloves
2. Closes all the clamps

3. Inserts the piercing pin (spike) into a container of 0.9 percent saline
solution using a twisting motion
4. Hangs the IV container on the IV pole
5. Squeezes the drip chamber of the normal saline until it covers one-
third of the drip chamber
6. Expels any residual air in the tubing
- 39 -
7. Starts the saline solution

8. Prepares the blood bag by inverting the blood bag gently several
times to mix the cells with the plasma
9. Closes the roller clamp of the filter set and attaches a needle at the
other end of the filter set
10. Exposes the part of the blood bag by pulling back the tabs
11. Inserts the spike of the filter set into the blood bag
12. Opens the clamp of the blood bag to prime the tubing then closes
the clamp
13. Closes the clamp on the IV saline solution
14. Inserts the needle of the blood bag to the Y- port of the saline IV
bottle then opens the clamp of the blood bag
15. Regulates the blood slowly for the first 10 minutes at 15 drops per
min.
16. Observes the patient closely for the first 15 minutes for any
reactions and take appropriate nursing action
17. Re adjusts the flow rate of the blood transfusion after 10 min.
STEP 3: MAINTAINING A BLOOD TRANSFUSION

1. Monitors the patient’s vital signs every fifteen minutes for one hour
after initiating the transfusion
2. Assesses the patient including vital signs every 30 minutes for the
next three hours until blood transfusion is finished
3. Alerts senior nurse if there is any untoward reaction during the
transfusion
STEP 4: TERMINATING A BLOOD TRANSFUSION
1. Puts on clean gloves
2. Clamps the blood tubing and disconnects needle from the Y-port
3. Opens the saline infusion clamp
4. Adjusts the saline drip to desired rate
5. Checks vital signs
STEP 5: AFTER CARE
1. Puts patient in a comfortable position
2. Discards the blood administration set according to agency policy
- 40 -
3. Puts needles in a labeled, puncture-resistant container
4. Follows agency protocol for appropriate disposal of the blood bag
5. Removes gloves and discards accordingly
STEP 6: DOCUMENTATION
Documents the procedure and all nursing assessment
a. Reason for the transfusion
b. Whether consent was signed
c. Time when blood transfusion was initiated
d. Type of blood transfused, amount, blood type, Rh factor, serial
number, expiration date and rate of flow
e. Any medication given prior to transfusion
f. Baseline vital signs
g. Any untoward reaction during the transfusion
h. Time when transfusion was terminated
Score = (No. of YES) / 41 x 100 = _____%
___________________________ ___________________________
- 41 -
MODULE 3: CHEST DRAINAGE/ CARE OF CLIENTS WITH CHEST TUBES
Learning Outcomes:
1. Identify indications for the use of chest tubes and accompanying signs and
symptoms.
2. Describe the risks/complications associated with chest tubes and chest drainage
units (CDUs).
3. Identify how to prepare/assist with the insertion of a chest tube.
4. Describe the monitoring of chest tubes and chest drainage systems.
5. Describe considerations in caring for the patient who has a chest tube, including
chest tube maintenance.
6. Identify factors that indicate when it is appropriate to discontinue the use of a chest
tube.
7. Describe how to assist with discontinuation of a chest tube.
Chest Drainage
The pleural cavity normally has negative pressure, any drainage system connected to it
must be sealed so that air or liquid cannot enter. Such a drainage system is called a
water-sealed drainage or a disposable pleural drainage system. Fluid in the bottom of
the container prevents air from entering the chest tube and thus from entering the
pleural cavity.
Chest tubes – made

Definitions
Pneumothorax: A collection of air in the pleural space. Note that pneumothorax is the
most common serious pleural complication in the Intensive Care Unit & the most
common reason for inserting a chest tube.
Tension pneumothorax: Occurs when air accumulates in the pleura space to the point of
causing a mediastinal shift pushing the heart, great vessels, trachea, and lungs toward
the unaffected side of the thoracic cavity.
- 42 -
Hemothorax: A collection of blood in the pleural cavity.

Hemopneumothorax: An accumulation of both air and blood in the pleural cavity.
Pleural effusion: Is excessive fluid in the pleura cavity.
Chylothorax: Is the accumulation of lymphatic fluid in the pleural space.
Empyema: Is a collection of purulent material from an infection like pneumonia.
Signs and Symptoms of a Tension Pneumothorax include:

• Severe respiratory distress
• Tracheal deviation toward the unaffected side
• Cyanosis
• Muffled heart sounds
• Cardiac arrest
Areas of Insertion of Chest tubes:

1. To remove air – usually inserted superiorly (2nd intercostal space) and anteriorly,
because air tends to rise in the pleural cavity
2. To drain fluid – inserted more inferiorly (8th or 9th intercostal space) and more
posteriorly
3. To drain both air and fluid – two chest tubes may be inserted. These are
sometimes joined externally by a Y-connector
Three mechanisms used:

1. Positive Expiratory Pressure – When pleural cavity contains some air or fluid, a
positive pressure develops during expiration. This is abnormal, but it does help
expel the air and to some extent, fluid from the space.
2. Gravity – acts as an evacuative force when the tubing is placed so that it
descends from the insertion site to the drainage receptacle
3. Suction – used in conjunction with the other two forces in some drainage
systems
- 43 -
The Basics of Chest Drainage Units (CDUs)

The Basic Operating System
A chest drainage unit is a device used to collect chest drainage (air, blood, effusions),
and connects to the end of the chest tube. Most commonly, drainage devices use a
single unit that has three chambers, based on the old three-bottle system. The three
chambers each provide separate functions of:
• Fluid collection
• Water seal (which serves as a simple one-way valve)
• Suction control
Kinds of Water-sealed Drainage Systems

• Glass Bottle System:
• 1 bottle
• The simplest form of underwater seal drainage systems. This system
can drain both fluid and air. The distal end of the drainage tube must
- 44 -
remain under the water surface level.There is always an outlet to the

atmosphere to allow air to escape.It is suitable for use with a simple
pneumothorax, when the vent is left open to the atmosphere, or
following a pneumonectomy when the tubing is clamped and released
hourly
• 2 bottle
• This system is suitable for the drainage of air and fluid. The first
chamber is for collection of fluid and the second is for the collection of
air. As the two are separate, fluid drainage does not adversely affect
the pressure gradient for evacuation of air from the pleural space. A
separate chamber for fluid collection enables monitoring of volume and
expelled matter.
• 3 bottle
• Suction is required when air or fluid needs a greater pressure gradient
to move from the pleural space to the collection system. Suction may
be applied via a third bottle or a suction chamber
• Plastic System:
• Thoraseal
• Pleuravac
- 45 -
Management of a Chest Tube Drainage System (Pleur-evac)

• A chest tube may be inserted at the bedside, in procedure room, or in the surgical suite.
Health care providers often assist physicians in the insertion and removal of a closed chest
tube drainage system.
• After initial insertion of a chest tube drainage system, assess the patient every 15 minutes to
1 hour. Once the patient is stable, and depending on the condition of the patient and the
amount of drainage, monitoring may be less frequent. If the patient is stable (vital signs within
normal limits; drainage amount, colour, or consistency is within normal limits; the patient is
not experiencing any respiratory distress or pain), assessment may be completed every 4
hours. Always follow hospital policy for frequency of monitoring a patient with a chest tube.
• Prior to managing a patient with a chest tube, review reason for the chest tube, the location of
the chest tube, normal volume of drainage, characteristics of the drainage, date of last
dressing change, and any previously recorded air leaks measurements.
• Safety/emergency equipment must always be at the patient’s bedside and with the patient at
all times during transportation to other departments. Safety equipment includes:
o Two guarded clamps
o Sterile water
o Vaseline gauze (Jelonet)
o 4 x 4 sterile dressing
o Waterproof tape
• Never clamp a chest tube without a doctor’s order or valid reason. The tube must remain
unobscured and unclamped to drain air or fluid from the pleural space. There are a few
exceptions where a chest tube may be clamped; see special considerations below.
• Chest tube drainage systems are replaced only when the collection chamber is full or the
system is contaminated.
1. Review the patient chart for

Knowing the reason for the chest tube and location informs
the reason for the chest tube
the health care provider on the type of expected drainage.
and location and insertion date.
2. Perform hand hygiene.

Hand hygiene reduces the transmission of microorganisms.
identify patient using two
- 46 -
identifiers and explain

assessment process to patient. Proper identification provides patient safety measures for
Create privacy to assess the safe care.
patient and drainage system.
Patient should be in a semi-Fowler’s position, have minimal

pain, have no respiratory distress, and have no evidence of
an air leak around the insertion site, and no drainage from
the insertion site or chest tube equipment.
Frequent assessment of the respiratory status is important

3. Complete respiratory
if the patient’s condition is stable, resolving, or
assessment, ensure patient has
worsening, and ensures that the chest tube is functioning
minimal pain, and measure vital
correctly.
signs. Place patient in semi-
Fowler’s position for easier
Assessment should be every 15 minutes to 1 hour until
breathing.
patient is stable. Increase monitoring if patient’s condition
worsens.
Chest tubes are painful, as the parietal pleura are very

sensitive. Ensure patient has adequate pain relief,
especially prior to repositioning, sitting, or ambulation.
Dressing should remain dry and intact; no drainage holes

should be visible in the chest tube.
Dressing is generally changed 24 hours post-insertion, then

every 48 hours. Chest tubes are generally sutured in place.
4. Assess chest tube insertion There should be no fluid leaking from around the site or
site to ensure sterile dressing is sounds of air leaks from insertion site.
dry and intact.
Check insertion site for

subcutaneous emphysema.
Chest tube insertion site
These measures are important to keep the system intact

5. Maintain a closed system.
and prevent accidental tube removal or disruption of the
Ensure all connections are
drainage system.
- 47 -
taped and secured according

to agency policy.
Kinked or bent tubing could interfere with the drainage of

the pleural fluid.
Dependent loops may collect fluid and impede drainage.
The long tube may be coiled and secured to a draw sheet

with a safety pin (allowing enough tubing so that the patient
6. Ensure tubing is not kinked
can move in bed comfortably) to prevent dependent loops.
or bent under the patient or in
the bed rails or compressed by
the bed.
Tubing free from kinks and dependent loops
The drainage system must remain upright for the water-

seal chamber to function correctly.
The chest drainage system must be lower than the chest to

7. Collection chamber
facilitate drainage and prevent back flow.
(drainage system) is below the
level of the chest and secured
to prevent it from being
accidentally knocked over.
Chest drainage system lower than insertion site
8. Periodically check water-seal Adequate water in the water-seal chamber prevents excess
chamber to ensure water level suction being placed on the delicate tissue.
is to the dotted line (2 cm) — at
least once every shift. Add Water levels should be checked each shift as the water
water as necessary. may evaporate.
9. Check water-seal chamber

If the water in the water seal does not move up and down
for tidaling (water moving up
with respirations, the system might not be intact or patent.
and down) or fluctuations with
Periodic bubbling in the water-seal chamber is normal and
respirations. Gentle bubbling is
indicates that air that is trapped is being removed. Frequent
normal as the lungs expand.
- 48 -
assessment of the system is required to ensure proper

functioning.
Chest tube drainage system with labelled parts
Excessive bubbling may cause unnecessary noise and

faster evaporation.
If there is no tidaling, consider 1) an occlusion somewhere

between the pleural cavity and the water seal, or 2) a full
expansion of the lung, where suction has drawn the lung up
against the holes in the chest tubes.
If patient is on positive pressure ventilation, the tidaling will

be the opposite: the water will move down with inspiration
and up with expiration.
10. Ensure suction control dial

The amount of suction in the chamber is regulated by the
is set to ordered level (usually
suction control dial, not the suction source.
20 cm).
11. If suction is ordered, a In wet suction control, gentle bubbling is normal. If there is
“float” (or equivalent) must be no bubbling, ensure the connections are tight and turn the
visible clearly in the window. suction higher.
- 49 -
Suction pressure set at – 20 cm
The suction port must be left open to the air and free of
obstruction to prevent a tension pneumonthorax.
12. If suction is not ordered,

ensure the suction port is left Suction port on the top of a chest tube drainage system
open to air. Suction window will
appear blank if suction is not in
use or not working.
Suction control window (white rectangle)
13. In wet suction Gentle bubbling is normal. Vigorous bubbling is noisy and
systems, expect gentle can be disturbing to the patient. Periodically check the air
bubbling in the chamber. vent to ensure it is not blocked or occluded.
Bubbling in the air leak meter indicates an air leak.

Measure and monitor.
14. Assess air leak meter to
determine progress of patient’s
The source of the leak may be identified by:
internal air level, measured as
level 1 to 7. On every shift,
• Checking and tightening connections.
document the level of air leak,
• Testing the tube for leaks (see special considerations
and if the air leak occurs at rest
below). If leak is in the tubing, replace the unit.
or with coughing.
• If the leak may be at the insertion site, remove the chest
tube dressing and inspect. Has the chest tube been pulled
- 50 -
out beyond the chest wall? If you cannot see or hear any
obvious leaks at the site, the leak is from the lung.
• Check patient history. Would you expect a patient air leak?
Notify doctor of any new, increased, or unexpected air

leaks that are not corrected by the above actions.
To document the air leak, note the numbered column

through which the bubbling occurs. If bubbling is present in
first three columns of the air leak meter, document “air leak
3.”
Air leak meter
The chest tube should not be clamped unless for specific

reasons. See special considerations below.
15. Check that the clamp is

open.
Blue clamp is open
16. Measure date and time, and Drainage that is red and free-flowing indicates a
the amount of drainage, and hemorrhage. A large amount of drainage, or drainage
mark on the outside of the that changes in colour, should be recorded and reported to
chamber. Record amount and the primary health care provider.
characteristics of the drainage
on the fluid balance sheet and Drainage that suddenly decreases may indicate a blood
patient chart. clot or obstruction in the chest tube drainage system.
- 51 -
Drainage in collection chamber
17. Encourage frequent

position changes as well as Deep-breathing and coughing exercises promote lung
deep-breathing and coughing expansion and promote fluid drainage.
exercises.
18. The following should be

documented and assessed
according to agency policy:
• Presence of air leaks
• Fluctuation of water in water-
seal chamber
• Amount of suction
Proper documentation is required to manage a chest tube
• Amount of drainage and type
drainage system to ensure it is functioning effectively.
• Presence of crepitus
(subcutaneous emphysema)
• Breath sounds
• Patient comfort level or pain
level
• Appearance of insertion site
and/or dressing
Data source: Bauman & Handley, 2011; BCIT, 2015c; Durai, Hoque, & Davies, 2010; Rajan,
2013; Teleflex Medical Incorporated, 2009
- 52 -
Special considerations:
• Do not strip or milk the chest tube: In practice, stripping is used to describe
compressing the chest tube with the thumb or forefinger and, with the other hand,
using a pulling motion down the remainder of the tube away from the insertion
site. Milking refers to techniques such as squeezing, kneading, or twisting the tube
to create bursts of suction to move clots. Any aggressive manipulation (compressing
the tube to dislodge blood clots) can generate extreme pressures in the chest tube.
There is no evidence showing the benefit of stripping or milking a chest tube
(Bauman & Handley, 2011; Durai et al., 2010; Halm, 2007).
• The only exceptions to clamping a chest tube are 1) if the drainage system is being
changed, 2) if assessing the system for an air leak, 3) if the chest tube becomes
disconnected from the chest drainage system — the chest tube should not be
clamped for more than a few minutes (Salmon, Lynch, & Muck, 2013), or 4) if the
condition of the patient is resolved and the chest tube is ready for removal (as per
physician orders).
- 53 -
Chest Drainage
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
Competencies YES NO
1. Review the patient chart for the reason for the chest tube and
location and insertion date.
2. Perform hand hygiene. identify patient using two identifiers and
explain assessment process to patient. Create privacy to
assess the patient and drainage system.
3. Complete respiratory assessment, ensure patient has minimal
pain, and measure vital signs. Place patient in semi-Fowler’s
position for easier breathing.
4. Assess chest tube insertion site to ensure sterile dressing is
dry and intact. Check insertion site for subcutaneous
emphysema.
5. Maintain a closed system. Ensure all connections are taped
and secured according to agency policy.
6. Ensure tubing is not kinked or bent under the patient or in the
bed rails or compressed by the bed.
7. Collection chamber (drainage system) is below the level of the
chest and secured to prevent it from being accidentally
knocked over.
8. Periodically check water-seal chamber to ensure water level is
to the dotted line (2 cm) — at least once every shift. Add water
as necessary.
9. Check water-seal chamber for tidaling (water moving up and
down) or fluctuations with respirations. Gentle bubbling is
normal as the lungs expand.
10. Ensure suction control dial is set to ordered level (usually 20
cm).
11. If suction is ordered, a “float” (or equivalent) must be visible
clearly in the window.
12. If suction is not ordered, ensure the suction port is left open to
air. Suction window will appear blank if suction is not in use or
not working.
13. In wet suction systems, expect gentle bubbling in the chamber.
- 54 -
14. Assess air leak meter to determine progress of patient’s

internal air level, measured as level 1 to 7. On every shift,
document the level of air leak, and if the air leak occurs at rest
or with coughing.
15. Check that the clamp is open.
16. Measure date and time, and the amount of drainage, and mark
on the outside of the chamber. Record amount and
characteristics of the drainage on the fluid balance sheet and
patient chart.
17. Encourage frequent position changes as well as deep-
breathing and coughing exercises.
18. The following should be documented and assessed according
to agency policy:
• Presence of air leaks
• Fluctuation of water in water-seal chamber
• Amount of suction
• Amount of drainage and type
• Presence of crepitus (subcutaneous emphysema)
• Breath sounds
• Patient comfort level or pain level
• Appearance of insertion site and/or dressing
Score = (No. of YES) / 18 x 100 = ______%
___________________________ ___________________________
- 55 -
MODULE 4: TRACHEOSTOMY CARE
Learning Outcomes:
1. List 3 indications for tracheostomy.
2. Describe key points of bedside respiratory assessment.
3. Identify signs of respiratory distress.
4. Identify types and sizes of tracheostomy tubes.
5. Recognize why, when and how to suction the tracheostomy tube.
6. Recognize why, when and how to clean the skin around the tracheostomy tube.
7. Recognize why, when and how to change the tracheostomy ties.
8. Recognize why and when to change the tracheostomy tube.
9. Recognize why, when and how to use respiratory and universal precautions.
Tracheostomy Care
This procedure is done every 8 hours while the dressing and tie tapes are changed
whenever necessary.
Equipment:
• Two sterile bowls for the cleaning solutions
• Cleaning solutions: Hydrogen peroxide (H2O2) and Sterile Normal Saline
• Sterile nylon brush or pipe cleaners
• Sterile gauze squares or sterile cotton-tipped applicator
• Sterile gloves
• Sterile 4x4 gauze squares
• Kidney basin
• Antibiotic ointment
• Plaster
• Tie tapes
• A clean glove
- 56 -
Concepts
Tracheostomy is a hole that surgeons make through the front of the neck and into the
windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for
breathing. The term for the surgical procedure to create this opening is tracheotomy.
A tracheostomy provides an air passage to help you breathe when the usual route for
breathing is somehow blocked or reduced. A tracheostomy is often needed when health
problems require long-term use of a machine (ventilator) to help you breathe. In rare
cases, an emergency tracheotomy is performed when the airway is suddenly blocked,
such as after a traumatic injury to the face or neck.
When a tracheostomy is no longer needed, it's allowed to heal shut or is surgically

closed. For some people, a tracheostomy is permanent.
Indications
Ssituations that may call for a tracheostomy include:
• Medical conditions that make it necessary to use a breathing machine (ventilator)
for an extended period, usually more than one or two weeks
• Medical conditions that block or narrow your airway, such as vocal cord paralysis
or throat cancer
• Paralysis, neurological problems or other conditions that make it difficult to cough
up secretions from your throat and require direct suctioning of the windpipe
(trachea) to clear your airway
• Preparation for major head or neck surgery to assist breathing during recovery
• Severe trauma to the head or neck that obstructs breathing
• Other emergency situations when breathing is obstructed and emergency
personnel can't put a breathing tube through your mouth and into your trachea
- 57 -
Emergency care
Most tracheotomies are performed in a hospital setting. However, in the case of an
emergency, it may be necessary to create a hole in a person's throat when outside of a
hospital, such as at the scene of an accident.
Emergency tracheotomies are difficult to perform and have an increased risk of
complications. A related and somewhat less risky procedure used in emergency care is
a cricothyrotomy). This procedure creates a hole directly into the voice box (larynx) at a
site immediately below the Adam's apple (thyroid cartilage).
Once a person is transferred to a hospital and stabilized, a cricothyrotomy is replaced
by a tracheostomy if there's a need for long-term breathing assistance.
- 58 -
Procedure
Competencies Rationale and Additional Information
A. PREPARATION
1. Introduces self to patient
2. Informs patient of the procedure To reassure the patient
and its importance
3. Assesses tracheostomy site Look for redness and signs of
infection
4. Prepares materials to be used To save time and effort
5. Drapes patient To maintain privacy
6. Does hand washing To prevent contamination
B. PROCEDURE
1. Opens tracheostomy set,
hydrogen Peroxide and sterile
saline
2. Dons sterile gloves keeping

dominant hand sterile
3. Pours Hydrogen Peroxide into
one tray and sterile Na Cl into
other
a. tray using non dominant
hand
4. Puts sterile brush & pipe

cleaners into H2O2 tray using
sterile gloves
5. Puts 4X4s and 1 cotton swab
into H2O2 tray and Na Cl tray,
keeping two 4X4s dry
6. Instructs re: deep breathing then

removes oxygen source if
present, with non-dominant
hand
- 59 -
7. Removes inner cannula; If

disposable, dispose
8. If not disposable, puts in To liquefy clogged secretions in the

hydrogen peroxide with brush tube
9. Washes inner cannula with To remove clogged secretions

brush
10. Holds cannula (sterile) over To remove H2O2, that is irritating to
basin and pours NaCl over the skin and surrounding tissues
cannula to rinse
11. Shakes off excess saline Expect to place the inner cannula
wet with saline. Saline acts as a
lubricant to prevent irritation.
12. Inserts inner cannula
13. Using 4X4s and cotton swab
from H2Os tray, cleans outer
cannula and stoma in circular
motion 4-8 cm from stoma
- 60 -
14. Uses 4X4s and swab from

saline tray to rinse area and pat dry
C. CHANGING TRACHEOSTOMY
TIES
1. Ties ends securely in double
square knot allowing space for
only one finger in tie or attaches
Velcro strips
- 61 -
2. Inserts fresh tracheostomy

dressing under clean ties and
faceplate
D. AFTER CARE
1. Positions patient comfortably
2. Does after care of all articles
and equipment used
E. DOCUMENTATION
1. Documents the procedure and
all nursing assessment
a. Time tracheostomy care
was done
b. Condition of
tracheostomy
c. If cannula was changed
d. Effect of tracheostomy
care to patient
- 62 -
Tracheostomy Care
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
A. PREPARATION YES NO
1. Introduces self to patient
3. Assesses tracheostomy site
4. Prepares materials to be used
5. Drapes patient
6. Does hand washing
B. PROCEDURE
1. Opens tracheostomy set, hydrogen Peroxide and sterile saline
2. Dons sterile gloves keeping dominant hand sterile
3. Pours Hydrogen Peroxide into one tray and sterile NaCl into other
tray using non dominant hand
4. Puts sterile brush & pipe cleaners into H2O2 tray using sterile
gloves
5. Puts 4X4s and 1 cotton swab into H2O2 tray and Na Cl tray,
keeping two 4x4s dry
6. Instructs re: deep breathing then removes oxygen source if
present, with non-dominant hand
7. Removes inner cannula; If disposable, dispose
8. If not disposable, puts in hydrogen peroxide with brush
9. Washes inner cannula with brush
10. Holds cannula (sterile) over basin and pours NaCl over cannula to
rinse
11. Shakes off excess saline
12. Inserts inner cannula
- 63 -
13. Using 4x4s and cotton swab from H2Os tray, cleans outer cannula
and stoma in circular motion 4-8 cm from stoma
14. Uses 4x4s and swab from saline tray to rinse area and pat dry
C. CHANGING TRACHEOSTOMY TIES
1. Ties ends securely in double square knot allowing space for only
one finger in tie or attaches Velcro strips
2. Inserts fresh tracheostomy dressing under clean ties and faceplate
D. AFTER CARE
1. Positions patient comfortably
2. Does after care of all articles and equipments used
E. DOCUMENTATION
• Time tracheostomy care was done
• Condition of tracheostomy
• If cannula was changed
• d. Effect of tracheostomy care to patient
Score = (No. of YES) / 25 x 100 = ____%
___________________________ ___________________________
- 64 -
MODULE 5a: NASOGASTRIC TUBE INSERTION
Learning Outcomes:
1. Understand the indications for the insertion of a nasogastric (NG) tube
2. Understand the indications for enteral tube feeding
3. Describe the potential contraindications and complications of NG tube insertion
4. Identify the appropriate equipment required for NG tube insertion
5. Demonstrate the ability to insert a NG tube and confirm placement.
Nasogastric intubation may be ordered by the physician for a variety of bowel problems.
Nasogastric (NG) intubation is a procedure in which a thin, plastic tube is inserted into
the nostril, toward the esophagus, and down into the stomach. The nurse is responsible
for inserting the nasogastric tube, assessing the patient during the period of nasogastric
tube insertion, and providing nursing care that ensures proper tube function and patient
comfort.
For most patients who cannot attain an adequate oral intake from food, oral nutritional
supplements, or who cannot eat and drink safely, they may be given proper nutrition via
nasogastric tube feeding.
The goal of this technique is to improve every patient’s nutritional intake and maintain
their nutritional status.
Nasogastric tube or NG tube is used in patients suffering from dysphagia due to their
inability to meet nutritional needs despite food modifications and because of the
possibility of aspiration.
- 65 -
Purposes
A nasogastric tube is a thin, pliable plastic tube that can be inserted into a patient’s
nose and threaded into the stomach. A nasogastric tube may be placed for the following
reasons:
• Gastric decompression
• Gastric analysis
• Gastric lavage/ gavage
EQUIPMENT
• Nasogastric tube (Fr 14 to 18 for adult) - The two most commonly used
nasogastric tubes are single-lumen Levin tube and the double-lumen gastric
sump tube.
• Gloves
• Water-soluble substance (K-Y jelly)
• Protective towel covering for client
• Emesis basin
• Tape for marking placement and securing tube
• Glass of water (if allowed)
• Straw for glass of water
• Stethoscope
• 60-mL catheter tip syringe
• Suction equipment or tube feeding equipment
- 66 -
Contraindications
• Nasogastric intubation is contraindicated in the following:

• Recent nasal surgery and severe midface trauma. These two are the absolute
contraindications for NG intubation due to the possibility of inserting the tube
intracranially. An orogastric tube may be inserted, in this case.
• Other contraindications include: coagulation abnormality, esophageal varices,
recent banding of esophageal varices, and alkaline ingestion.
Risks and Complications

As with most procedures, NG tube insertion is not all beneficial to the patient as certain
risks and complications are involved:
The main complication of NG tube insertion include aspiration.
A conscious patient may feel a little discomfort while the NG tube is passed through the
nostril and into the stomach which can induce gagging or vomiting. A suction should
always be present and ready to be used in this case.
The tube can injure the tissue inside the sinuses, throat, esophagus, or stomach if not
properly inserted.
Wrong placement. Unwanted scenarios such as wrong placement of an NG tube into
the lungs will allow food and medicine pass through it that may be fatal to the patient.
Other complications include: abdominal cramping or swelling from feedings that are too
large, diarrhea, regurgitation of the food or medicine, a tube obstruction or blockage, a
tube perforation or tear, and tubes coming out of place and causing additional
complications
An NG tube is meant to be used only for a short period of time. Prolonged use can lead
to conditions such as sinusitis, infections, and ulcerations on the tissue of your sinuses,
throat, esophagus, or stomach.
- 67 -
PROCEDURE
1. Introduce yourself and verify the client’s identity. Explain to the client what you are
going to do. Why it is necessary, and how the client can cooperate.
2. Perform hand hygiene and observe other appropriate infection control procedure
3. Assess the client nares oral cavity
4. Check the chart for doctor’s order of nasogastric tube insertion
5. Prepare necessary equipment and supplies
6. Provide for client privacy
7. Position client in high fowler’s position with pillows behind head and shoulders.
Raise the head of the bed
8. Stand on client right side, if right handed and left side if left handed
9. If the NGT is too pliable, place the tube in emesis basin and cover with ice
10. Instruct client to relax & breathe normally while occluding one nostril then repeat this
action to the other nostril. Select the nostril with greater air flow
11. Use the tube to mark off the distance from the tip of the client’s nose to the top of the
earlobe and then from the tip of the earlobe to the tip of the xyphoid process of the
sternum.
12. Mark the length of the tube with adhesive tape, if the tube does not have markings
13. Put on the gloves
14. Lubricate the tip of the tube well with water. Soluble lubricant
- 68 -
15. Insert the tube, with its natural curved toward the client, into the selected nostril. Ask
the client to hyper extend the neck, and gently advance the tube toward the
nasopharynx
16. Direct the tube along the floor the nostril and toward the ear on that side
17. Slight pressure is sometimes required to pass the tube into nasopharynx, and some
client eyes nay water at this point. Provide the client with tissues as needed
18. If the tube meets resistance, withdraw it relubricate it, and insert it in the other
nostril.
19. Once the tube reaches the oropharynx (throat), the client will feel the tube in the
throat and may gag and retch. Ask the client to tilt head forward, and encourage the
client to drench and swallow
20. If client gags, stop passing the tube momentarily, have the client rest, take a few
breaths and take rips of water to calm the gag reflex
21. In cooperation with the client, pass the tube 5-10 cm (2-4 inches) with each swallow
until it indicated length is inserted
22. If the client begins to cough, gag or choke, stop the advancement. If client continues
to cough pull the tube back slightly
23. As certain correct placement of the tube
• Aspirate stomach contents
• X-ray as per agency policy
• Place stethoscope over the client epigastric, and inject 10-30 ml of air into the
tube while listening for a whooshing sound
24. If the signs do not indicate placement in the stomach advance the tube 5cm
(2inches) and repeat the test
25. Secure the tube by taping it to the bridge of the client’s nose
26. Attach the tube to a section source of feeding apparatus as ordered, or the clamp
the end of the tubing
27. Document the insertion of the tube.
- 69 -
Nasogastric Tube Insertion
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
CRITERIA YES NO
1. Introduce yourself and verify the client’s identity. Explain to the client
what you are going to do. Why it is necessary, and how the client can
cooperate
2. Perform hand hygiene and observe other appropriate infection control
procedure
3. Assess the client nares oral cavity
4. Check the chart for doctor’s order of nasogastric tube insertion
5. Prepare necessary equipment and supplies
6. Provide for client privacy
7. Position client in high fowler’s position with pillows behind head and
shoulders. Raise the head of the bed
8. Stand on client right side, if right handed and left side if left handed
9. If the NGT is to pliable, place the tube in emesis basin and cover with
ice
10. Instruct client to relax & breath normally while occluding one nostril
then repeat this action to the other nostril. Select the nostril with
greater air flow
11. Use the tube to mark off the distance from the tip of the client’s nose
to the top of the earlobe and then from the tip of the earlobe to the tip
of the xyphoid process of the sternum
12. Mark the length of the tube with adhesive tape, if the tube does not
have markings
13. Put on the gloves
14. Lubricate the tip of the tube well with water. Soluble lubricant
15. Insert the tube, with its natural curved toward the client, into the
selected nostril. Ask the client to hyper extend the neck, and gently
advance the tube toward the nasopharynx
16. Direct the tube along the floor the nostril and toward the ear on that
side
- 70 -
17. Slight pressure is sometimes required to pass the tube into nasopharynx,
and some client eyes nay water at this point. Provide the client with tissues
as needed
18. If the tube meets resistance, withdraw it relubricate it, and insert it in the
other nostril
19. Once the tube reaches the orapharynx ( throat), the client will feel the tube
in the throat and may gag and retch. Ask the client to tilt head forward, and
encourage the client to drench and swallow
20. If client gags, stop passing the tube momentarily, have the client rest, take a
few breath and take rips of water to calm the gag reflex
21. In cooperation with the client, pass the tube 5-10 cm ( 2-4 inches) with each
swallow until it indicated length is inserted
22. If the client begin to cough, gag or choke, stop the advancement. If client
continues to cough pull the tube back slightly
23. As certain correct placement of the tube
• Aspirate stomach contents
• X-ray as per agency policy
• Place stethoscope over the client epigastric, and inject 10-30 ml of air into
the tube while listening for a whooshing sound
24. If the signs do not indicate placement in the stomach advance the tube 5cm
(2inches) and repeat the test
25. Secure the tube by taping it to the bridge of the clients nose
26. Attach the tube to a section source of feeding apparatus as ordered, or the
clamp the end of the tubing
27. Document the insertion of the tube
Score = (No. of YES) / 27 x 100 = _____%
___________________________ ___________________________
- 71 -
MODULE 5b: NASOGASTRIC TUBE FEEDING
Nasogastric tube feeding is a method of supplying nutrients directly into the

gastrointestinal. A wide range of patients may require NGT feeding either for a short or
long period of time for a variety of reasons including:
1. Unable to consume adequate nutrients

2. Impaired swallowing/sucking
3. Facial or esophageal structural abnormalities
4. Anorexia related to a chronic illness
5. Eating disorders
6. Increased nutritional requirements,
7. Congenital anomalies
8. Primary disease management.
Purpose:
NGT feeding aims to administer feeds and medications via a nasogastric tube in a safe
and appropriate manner.
Supplies and Equipment

• Gloves
• Clamp (optional)
• Feeding solution
• Large catheter tip syringe (30 mL or larger)
• Water
• Measuring cup
• Other optional equipment (disposable pad, pH indicator strips, paper towels)
• Feeding pump (if ordered)
Assessment
Prior to accessing an NGT nursing staff members must ensure that the tube is located
in the stomach. Coughing, vomiting and movement can move the tube out of the correct
position. The position of the tube must be checked:
- 72 -
1. Prior to each feed/ medication

2. Before each medication.
3. Ensure taping is secure
4. Observe and document the position marker on NGT/OGT – compare to initial
measurements.
5. Observe for any signs of respiratory distress
PREPARATION
1. Checks the doctor’s order

4. Performs handwashing
6. Elevates head of bed at least 30 to 45-degree angle
7. Prepares feeding and allow to reach room temperature before feeding
PROCEDURE
1. Stand on patient’s left side, if right handed and right side if left handed. Put a towel
on top of patient’s chest
2. Puts on gloves
3. Checks for correct placement of tube by injecting 3-5 ml of air and listens for a
whooshing or gurgling sound
- 73 -
4. Clamps the tube and inserts the tip of the asepto-syringe to end of gastric tube
5. Aspirates the tubing to check and measure amount of residual
6. Flush NGT with 15 to 30 ml water
7. Pours feeding into the asepto syringe
8. Raises the syringe 12 to 18 inches above the stomach or at the level of patient’s
forehead (Depends on consistency of feeding). Opens the clamp.
9. Allows feeding to flow by gravity into the stomach. Raise and lower the syringe to
control the rate of flow
10. Adds feeding to the asepto syringe as it empties, not allowing the syringe to become
empty until feeding is completed
11. Terminates feeding when completed and flush with appropriate amount of water (15
to 30 ml)
12. Kinks or closes the end of the feeding tube
13. Removes gloves and performs hand hygiene
AFTER CARE
1. Keeps the patient’s head elevated for 20-30 min.

2. Performs after care of all articles and equipment used
DOCUMENTATION
1. The nature of aspirate, color, amount

2. The amount of feeding and water given
3. The patients’ reaction to feeding
- 74 -
NGT Feeding
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
1. Checks the doctor’s order
6. Elevates head of bed at least 30 to 45 degree angle
7. Prepares feeding and allow to reach room temperature before feeding
B. PROCEDURE
1. Stands on patient’s left side, if right handed and right side if left handed.
Puts a towel on top of patient’s chest
2. Puts on gloves
3. Checks for correct placement of tube by injecting 3-5 ml of air and listens
for a whooshing or gurgling sound
4. Clamps the tube and inserts the tip of the asepto syringe to end of gastric
tube
5. Aspirates the tubing to check and measure amount of residual
6. Flush NGT with 15 to 30 ml water
7. Pours feeding into the asepto syringe
8. Raises the syringe 12 to 18 inches above the stomach or at the level of
patient’s forehead (Depends on consistency of feeding). Opens the clamp.
9. Allows feeding to flow by gravity into the stomach. Raise and lower the
syringe to control the rate of flow
10. Adds feeding to the asepto syringe as it empties, not allowing the syringe
to become empty until feeding is completed
- 75 -
11. Terminates feeding when completed and flush with appropriate amount of
water (15 to 30 ml)
12. Kinks or closes the end of the feeding tube
13. Removes gloves and performs hand hygiene
C. AFTER CARE
1. Keeps the patient’s head elevated for 20-30 min.
2. Performs after care of all articles and equipment used
D. DOCUMENTATION
• The nature of aspirate, color, amount
• The amount of feeding and water given
• The patients’ reaction to feeding
Score = (No. of YES) / 23 x 100 = _____%
___________________________ ___________________________
- 76 -
MODULE 6: COLOSTOMY CARE

Learning Outcomes:
1. Identify key elements to include when assisting with/or providing basic preoperative
education for a patient undergoing a colostomy, ileostomy, or incontinent urinary
diversion.
2. Discuss the importance and established guidelines for preoperative stoma site
marking.
3. Evaluate the viability of the stoma, function of the ostomy, and status of the
peristomal skin.
4. Differentiate the distinguishing characteristics of common stomal and peristomal
complications.
5. Identify appropriate strategies for management of common stomal and peristomal
complications.
COLOSTOMY - Is an opening that is made on the colon with surgery
• After an opening is made the colon is brought to the surface of the abdomen to
allow stools to leave the body.
• STOMA – the opening at the surface of the abdomen
- 77 -
The stools leave the colon through the stoma and drains into a flat, changeable,
watertight bag or pouch
Where is the colon located?
The colon is part of the digestive system. The digestive system consists of the parts of
the body that are involved in the digestion (breakdown) of food. Food moves from your
stomach to the small intestine where food is digested and nutrients are absorbed. The
food then goes to the colon (part of the large intestine). The colon absorbs water from
digested food and turns the digested food into stool.
Types of Ostomies according to organs involved:
1. To provide an alternate feeding route:
a. Gastrostomy – opening through the abdominal wall into the stomach
b. Jejunostomy- opening through the abdominal wall into the jejunum
2. To divert and drain fecal material
a. Ileostomy – opening through the abdominal into the ileum (small bowel) drains out
liquid feces with some digestive enzymes damaging to the skin, there is minimal odor
because there are fewer bacteria present, drains constantly.
a. Colostomy – opening through the abdominal wall into the colon (large bowel)
- 78 -
Type of Colostomies according to permanence:
1.Temporary colostomies
• For traumatic injuries

• For inflammatory conditions of the bowel
• To allow the distal diseased portion of the bowel to rest and heal
2. Permanent colostomies - to provide a means of elimination when the rectum or

anus is nonfunctional as a result of disease or birth defect like CA of the bowel
- 79 -
Colostomy Care
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
CRITERIA YES NO
PROCEDURE
1. Assist the client to a comfortable sitting or lying position and expose only
the stoma area
2. Don Gloves
3. Empty the pouch when 1/3 to ½ full & assess for the consistency &
amount of effluent
4. Remove the appliance and discard.
5. Using warm water and mild soap, clean the peristomal skin and the
stoma
6. Dry the area thoroughly by patting with a towel or cotton swabs
7. Assess the stoma & peristomal skin. Place a piece of tissue or gauze pad
over the stoma, and change it as needed
8. Measure the size of the stoma by tracing a circle on the backing of the
skin barrier the same size as the stomal opening. Cut out the traced
stoma pattern to make an opening in the skin barrier. Remove the
backing to expose the sticky adhesive side.
9. Remove the tissue or gauze pad on the stoma
10. Center the skin barrier over the stoma & gently press it onto the skin,
smoothing out any wrinkles or bubbles
11. Remove the air from the pouch
Score = (No. of YES) / 11 x 100 = _____%
___________________________ ___________________________
- 80 -
MODULE 7: NEUROLOGIC ASSESSMENT
Learning Outcomes:
At the end of the discussion, the student will be able to:
• Assess the client for clinical manifestations of common nervous system disorders
• Properly perform the indicated neurological assessment for the client
• Develop critical thinking in the assessment of clients with possible and actual
neurologic disorders
Purposes of Neurologic Assessment

• To collect baseline data to aid in establishing the etiology, diagnosis and prognosis
• To evaluate the present state of psychological functioning
• to evaluate changes in individual’s emotional, intellectual, motor, and perceptual
responses
• To determine the guidelines of treatment plan
• To ascertain if some seemingly psychopathological response, is in fact a disorder of
the sensory organ (i.e., a deaf person appearing hostile)
Three important questions govern the neurologic examination:

1) Is the mental status intact?
2) Are right-sided and left-sided findings symmetric?
3) If the findings are asymmetric or otherwise abnormal, does the causative lesion lie in
the CNS or the peripheral nervous system?
- 81 -
Equipment
The following tools will be used during the
neurological exam:
• Gloves
• Reflex hammer (tomahawk model)
• Penlight
• Tongue blade
• Neurologic Safety pin
• Cotton swab
• Ophthalmoscope
• Eye chart (Snellens’s or Pocket Eye depeding on client’s condition)
• Tuning fork
• Coffee
PROCEDURE
Preparation
1. Introduces self to patient and verifies paHent’s name
3. Gathers articles needed for neurologic assessment
4. Asks patient to put on a gown
5. Positions and drapes patient
Mental Status Assessment

1. Assesses level of consciousness
2. Observes appearance and behavior
3. Observes mood, feelings and expression
4. Observes thought processes and perceptions
5. Observes cognitive abilities
- 82 -
General appearance, manner and attitude

A simple means of gathering a great deal of information about the patient's neurological
system is to observe the patient walking, talking, seeing, and hearing. Watching the
patient enter the room is also important in giving the examiner information.
As the patient enters the room, check the following:
• Posture and motor behavior, purposeful movements and gestures
• Dress, grooming, and personal hygiene.
• Facial expression.
• Speech manner, mood, and relation to persons and things around him
Level of consciousness - The single most valuable indicator of neurological function is

the individual's level of consciousness. You can legally describe the patient's condition
in the nursing notes by saying, "appears to be" alert or lethargic or so forth.
• Alert. The patient is awake and verbally and motor responsive.
• Confused. The patient may de disoriented to time, place and person and has poor
judgment and may not think clearly.
• Lethargic. The patient is sleepy or drowsy and will awaken and respond appropriately
to command.
• Obtundation. The patient is difficult to arouse and needs constant stimulation to follow
commands. He may respond with a few words but will drift back to sleep when the
stimulus is removed
• Stupor. The patient becomes unconscious spontaneously and is very hard to awaken.
• Semi coma. The patient is not awake but will respond purposefully to deep pain.
• Coma. The patient is completely unresponsive.
***Consciousness is the most sensitive indicator of neurological change**
The Cranial Nerves

Evaluating the cranial nerves is an important part of the neurological examination. Taste
and smell are usually not checked unless a problem is suspected in those areas.
- 83 -
Cranial Nerve I, The Olfactory Nerve

• The olfactory nerve is not commonly tested during a screening physical exam but
can be performed if damage secondary to trauma or intracranial mass is suspected.
• Each nostril should first be evaluated for patency by compressing one nostril and
having the patient breath through the opposite.
• Each nostril should then be tested separately with a volatile, non-irritating substance
such as cloves, coffee or vanilla.
• The patient should close his eyes, occlude one nostril and identify the substance
placed under the open nostril.
Cranial Nerve II, The Optic Nerve

Vision: Visual Acuity To examine cranial nerve II and ocular function
• Position yourself in front of the patient. Test the patient's visual acuity, each eye
separately covering one at a time.
• Snellen's chart is used by Ophthalmologists. Visual acuity is recorded as a fraction.
The numerator indicates the distance (in feet) from the chart which the subject can
read the line .
• The denominator indicates the distance at which a normal eye can read the line.
Normal vision is 20/20.
• A pocket screener is used at the bedside. Hold the pocket screener at a distance of
12-14 inches. At this distance the letters are equivalent to those on Snellen's chart.
What if patient has glasses or corrective lenses?

Have them removed first:
• Test BOTH EYES OPEN
• Then TEST RIGHT EYE (OD)
• Then TEST LEFT EYE (OS)
Repeat above process but with glasses ON
- 84 -
Vision field by confrontation

• Position yourself in front of the patient.
• The nose normally cuts off the medial field of vision. Hence, compare the patient's
right eye to your left eye and vice versa.
• Instruct the patient to look straight at you and not to move their eyes.
• Compare your field of vision with the subject's.
• Bring your finger from the right field of vision until it is recognized.
• Test one quadrant at a time.
• Wiggle your fingers to see whether the patient can recognize the movement.
• Some like to have the patient count fingers, i.e., 1, 2 or 5. Test all four quadrants in a
similar fashion.
• When abnormality is detected, would require automated methods of testing in the
lab
Extraocular Muscles
• To examine cranial nerves III, IV and VI Inspect the eyes. Look for symmetry of
eyelids. Note the alignment of the eyes at rest.
• Ductions: Movement of one eye at a time
• Versions: Both eye movement Have the patient follow an object into each of the nine
cardinal fields of gaze. Note that both eyes move together into each field. Eye
movements should be smooth and without jerking.
• Eyelids should be gently lifted up by the examiner's fingers when testing downward
gaze. Jerky, oscillatory eye movements (nystagmus) may be abnormal, especially if
sustained or asymmetrical.
• Pupils: To examine cranial nerves II , III and mid-brain connections
PUPILLARY ASSESSMENT
When assessing pupils (eyes) it is important to assess the following: size shape
reactivity to light comparison of one pupil to the other Pupils: Reaction to Light
- 85 -
To examine cranial nerves II , III and mid-brain connections Have the patient look at a
distant object Look at size, shape and symmetry of pupils.
Shine a light into each eye and observe constriction of pupil.
Flash a light on one pupil and watch it contract briskly.
Flash the light again and watch the opposite pupil constrict (consensual reflex Repeat
this procedure on the opposite eye. Normal: Pupil size is 3-5 mm in diameter. They
react briskly to light. Both pupils constrict consensually.
Pupils: Size To examine cranial nerves II , III and mid-brain connections Pupils can be
described according to their size (in mm) or by description:
Pinpoint: Seen with opiate overdose and pontine hemorrhage.
Small: Normal if the person is in a bright room. May be seen with Horner's syndrome,
pontine hemorrhage, ophthalmic drops, metabolic coma etc.
Midposition: Seen normally. If pupils are midposition and nonreactive the cause is
midbrain damage.
Large: Seen normally when the room is dark. May be seen with some drugs and some
orbital injuries.
Dilated: Always an abnormal finding. Bilateral, fixed and dilated pupils are seen in the
terminal stage of severe anoxiaischemia or at death. Anti-cholinergic drugs can dilate
pupils
CN V: Trigeminal Corneal reflex: patient looks up and away.

• Touch cotton wool to other side. • Look for blink in both eyes, ask if can sense it. •
Repeat other side [tests V sensory, VII motor]. Facial sensation: sterile sharp item on
forehead, cheek, jaw. • Repeat with dull object. Ask to report sharp or dull. • If abnormal,
then temperature [heated/ water-cooled tuning fork], light touch [cotton]. Motor: pt opens
mouth, clenches teeth (pterygoids). • Palpate temporal, masseter muscles as they
clench.
CN V: Trigeminal Facial sensation: sterile sharp item on forehead, cheek, jaw. •

Repeat with dull object. Ask to report sharp or dull. • If abnormal, then temperature
- 86 -
[heated/ water-cooled tuning fork], light touch [cotton]. Motor: pt opens mouth, clenches
teeth (pterygoids). • Palpate temporal, masseter muscles as they clench.
CN V: Trigeminal Sensory: • Do not test routinely. Test only when you suspect
FACIAL NERVE INJURY. • When indicated, test sense of taste by applying a cotton
applicator covered with SUGAR, SALT, or LEMON JUICE (sour). • Ask the person to
identify the taste. Motor Function: Facial Muscles To test cranial nerve VII Inspect the
face. Look for asymmetry at rest, during conversation and when testing various
muscles. Ask the patient to wrinkle his forehead or raise his eyebrows, enabling you to
test the upper face (frontalis)
CRANIAL NERVE VII

To test cranial nerve VII Next, have the patient tightly close his eyes. Test the strength
of the orbicularis oculi by gently trying to pry open the patient's upper eyelid. Instruct
him to puff out both cheeks. Check tension by tapping his cheeks with your fingers.
Have the patient smile broadly and show his teeth, testing the lower face. Motor
Function: Facial Muscles To test cranial nerve VII Normal: No facial asymmetry.
Wrinkling of the forehead and smiling are equal and symmetrical
CRANIAL NERVE VIII

CNVIII: Hearing With eyes closed, the patient should be instructed to acknowledge
hearing the gentle rubbing of the examiner's fingers approximately 3-4 inches away
from his right and left ear. A watch, which the examiner can hear at a specific distance
from his ear, is placed next to the patient's ear. Ask him to note when the watch sound
disappears. Note that the examiner has to have normal hearing to do this exam (in at
least one ear) Normal: In a quiet room, the patient should be able to hear the examiner's
fingers rubbed lightly together 3-4 inches from his ear.
CNVIII: Hearing Whisper Test. Test one ear at time while masking hearing in the other
ear to prevent sound transmission around the head. This is done by placing one finger
on the tragus and rapidly pushing it in and out of the auditory meatus. Shield your lips
- 87 -
so the person cannot compensate for a hearing loss (consciously or unconsciously) by

lip reading or using the “good ear”. Distance should be 30 to 60 cm (1 to 2 ft) from the
person’s ear, exhale and whisper slowly some two syllable words like seven, Tuesday,
baseball
CNVIII: Hearing Weber Test (Air Conduction) This is valuable when a person reports
hearing better with one ear than the other. Place a vibrating tuning fork in the midline of
the person’s skull and ask if the tone sounds the same in both ears or better in the other
one. The person should hear the tone by bone conduction through the skull, and it
should sound equally in both ears.
CNVIII: Hearing Rinne Test (Air and Bone Conduction) Compares air conduction and
bone conduction sound. Place the stem of the vibrating tuning fork on the person’s
mastoid process and ask him or her to signal when the sound goes away. Quickly invert
the fork so the vibrating end is near the ear canal; the person should still hear a sound.
Normally, the sound is heard twice as long as air conduction (next to the ear canal) as
by bone conduction (through the mastoid process) Normal response is (+) Rinne Test
AC > BC. Repeat with other ear.
CRANIAL NERVE IX and X

CN IX and X These tests will evaluate certain structures in the mouth. The nurse ask
the patient to say "aah" and can detect abnormal positioning of certain structures such
as the palateluvula. The examiner will also assess the sensation capabilities of the
pharynx, by stimulating the area with a wooden tongue depressor, causing a gag reflex.
CRANIAL NERVE XI
CNXI Inspect Trapezius and Sternocleidomastoid muscles Note muscle size (bulk).
Look for asymmetry, atrophy and fasciculation. Determine muscle power by gently
trying to overpower contraction of each group of muscles. Have patient shrug shoulder
against resistance and evaluate strength of Trapezius muscle. Have patient turn head to
- 88 -
one side against resistance and evaluate strength and observe contracting
sternomastoid muscle
CRANIAL NERVE XII

CNXII This nerve tests the bulk and power of the tongue. The examiner looks for tongue
protrusion and/or abnormal movements
Motor and Cerebellar Function

II. The Cerebellar Functions These include tests for balance and coordination.
The cerebellum controls the skeletal muscles and coordinates voluntary muscular
movement.
Ask the patient to walk back and forth across the room. Observe for equality of arm
swing , balance and rapidity and ease of turning.
Cerebellar Functions
1. Finger to finger test: have the patient touch their index finger to your index finger
(repeat several times).
2. Finger to nose test: perform with eyes open and then eyes closed. Cerebellar
Functions
3. Tandem walking: heel to toe on a straight line
4. Romberg test The Romberg Test • Instruct the patient to stand with his feet together
and his arms at his side. • Have the patient do this with his eyes open and then with his
eyes closed. (Stand close to the patient to keep him upright if he starts to sway.) •
Expect the patient to sway slightly but not fall. This is a test of balance. • If the patient
begins to sway, have them open their eyes. If swaying continues, the test is “positive” or
suggestive of problem of cerebellum Rapid alternating movements test • Seat the
patient. Instruct him to pat his knees with his hands, palms down then palms up. Have
him alternate palms down and palms up rapidly. • Watch the patient to notice if his
movements are stiff, slow, non-rhythmic, or jerky. • The movements should be smooth
and rhythmic as he does the task faster.
- 89 -
Sensory Functions
Sensory Function Testing for sensory function is the most difficult and the least reliable
part of the examination. Perform two tests. (1) Test for pain. Perform this test using pin
pricks in the arms and legs. Ask the patient to say "sharp" or "dull" after each stimulus
and to reply immediately. This is a test of the patient's response to superficial pain.
Usually, a sterile needle with a sharp point and dull hub on the other end is the
instrument used. In a non-predictable pattern, touch the patient's skin with one or the
other end of the needle. Test for touch (Fine) Touch the skin with a cotton ball using
light strokes. Do not press down on the skin or touch areas of the skin that have hair. •
Stereognosis • Graphesthesia
Test for Temperature

Testing for temperature sensation is often overlooked but it can be important. Tubes of
hot and cold water may be used but an easier and more practical approach is often to
touch the patient with a tuning fork as the metal feels cold. First touch the patient where
sensation is thought to be normal and say, "Does that feel cold?" Then, when testing
the limb, check that the patient is feeling the fork as cold and not just as pressure Test
for Vibration Sensation Test the person’s ability to feel vibrations of a tuning fork over
bony prominences. Use a low-pitch tuning fork (128 Hz to 256 Hz) because its vibration
has a slower decay. Strike the tuning fork on the heel of your hand, and hold the base
on a bony surface. Ask the person to indicate when vibration starts and stops. Normally,
vibrations will be felt
Positioning/ Position Sense

Usually tested only on the great toes but it can be tested on the fingers too. Ask the
patient to shut his eyes. Grasp the side of the toe between index finger and thumb. This
prevents movement from being felt as pressure up or down. Move the digit up or down
and ask the patient to tell you the direction of movement
- 90 -
The Reflexes
A reflex is defined as an immediate and involuntary response to a stimulus. Superficial
reflexes. Stroke the skin with a hard object such as an applicator stick. What is felt is a
superficial reflex •5 Ps –Pain –Pallor –Pulses –Paresthesia –Paralysis
Biceps--deep tendon reflex

1- Have the patient's elbow at about a 90° angle of flexion with the arm slightly bent
down as shown in figure. 2- Grasp the elbow with your left hand so the fingers are
behind the elbow and your abductee thumb presses the biceps brachial tendon.
3- Strike your thumb a series of blows with the rubber hammer, varying your thumb
pressure with each blow until the most satisfactory response is obtained.
4- Normal reflex is elbow flexion (bending)
Triceps--deep tendon reflex

Grasp the patient's wrist with your left hand and pull his arm across his chest so the
elbow is flexed about 90° and the forearm is partially bent down.
Tap the triceps brachial tendon directly above the olecranon process.
The normal response is elbow extension. Triceps reflex Triceps jerk with arms folded
Triceps jerk with one arm.
Plantar (Babinski) reflex Lightly stimulate the outer margin of the sole of the foot to get
this reflex. Perform the reflex check in this manner: Grasp the ankle with your left hand.
Use a blunt point and moderate pressure and stroke the sole of the foot near its lateral
border. Stroke from the heel toward the ball of the foot where the course should curve
across the ball of the foot to the medial side, following the bases of the toes. A normal
reflex is for the patient to have plantar flexion of all his toes.
Patellar reflex (kneejerk) Test the reflex in this manner

1 -Have the patient sit on a table or high bed to allow his legs to swing freely.
2 -Tap the patellar tendon directly with a rubber hammer.
3 -Normally, the knee extends.
- 91 -
4 -Conduct the reflex check as shown in this figure if the patient must be lying down. Put
your hand under the popliteal fossa and lift the patient's knee from the table or bed. Tap
the patellar tendon directly.
Achilles reflex (ankle jerk)

Tap the Achilles tendon and the foot should extend from the contraction of the
gastrocnemius and soleus muscles responding to that tap.
Perform the reflex test in this manner:
Have the patient sit on a table or bed so that his legs dangle.
With your left hand, grasp the patient's foot and pull it in dorsiflexion (upward).
Find the degree of stretching upward of the Achilles tendon that produces the optimal
response.
Tap the tendon directly.
Normal response is contraction of the gastrocnemius and plantar flexion of the foot.
Achilles reflex (ankle jerk)
Deep tendon reflexes should be graded on a scale of 0-4 as follows: = 0 absent despite
reinforcement = 1 present only with reinforcement = 2 normal = 3 increased but normal
= 4 markedly hyperactive, with clonus
Test for Abnormal Reflexes

Brudzinski’s Reflex
• Characterized by reflexive flexion of the knees and hips following passive neck flexion.
• To elicit this sign, the examiner places one hand on the patient's chest and the other
hand behind the patient's neck.
• The examiner then passively flexes the neck forward and assesses whether the
knees and hips flex.
• Upon passive neck flexion, a positive test results when the patient flexes his knees
and hips.
• During the process of performing the test, the hand on the chest prevents the patient
from reflexively lifting his chest off the bed which decreases the specificity of the test.
- 92 -
Kernig Sign
A sign indicating the presence of meningitis (inflammation of the meninges covering the
brain and spinal cord). The test for Kernig sign is done by having the person lie flat on
the back, flex the thigh so that it is at a right angle to the trunk, and completely extend
the leg at the knee join If the leg cannot be extended, due to PAIN, then this is a
positive KERNIG SIGN Aftercare and Documentation
- 93 -
Neurological Assessment
Name : ______________________________________ Score: ___________________

Sec/Grp: ___________________________ Date : ___________________
3. Gathers articles needed for neurologic assessment
4. Asks patient to put on a gown
5. Positions and drapes patient
B. MENTAL STATUS
1. Assesses level of consciousness
2. Observes appearance and behavior
3. Observes mood, feelings and expression
4. Observes thought processes and perceptions
5. Observes cognitive abilities
C. CRANIAL NERVE ASSESSMENT
1. Cranial Nerve I – Olfactory
2. Cranial Nerve II – Optic
3. Cranial Nerve III – Oculomotor
4. Cranial Nerve IV – Trochlear
5. Cranial Nerve VI – Abducens
6. Cranial Nerve V – Trigeminal
7. Cranial Nerve VII – Facial
8. Cranial Nerve VIII – Acoustic
9. Cranial Nerve IX – Glossopharyngeal
10. Cranial Nerve X – Vagus
11. Cranial Nerve XI – Spinal Accessory
12. Cranial Nerve XII - Hypoglossal
D. MOTOR AND CEREBELLAR SYSTEM
1. Tests condition and movement of muscles
2. Tests balance
3. Tests coordination
E. SENSORY SYSTEM
1. Tests light, touch, pain and temperature sensations
2. Tests vibratory sensation
- 94 -
3. Tests position sensation

4. Tests tactile discrimination (fine touch)
F. REFLEXES
1. Tests deep tendon reflexes (biceps, brachio radialis, triceps, patellar
Achilles and ankle clonus)
2. Tests superficial reflexes (plantar, abdominal, cremasteric)
3. Tests for meningeal irritation/inflammation (Brudzinski ‘s and Kernig’s
sign if indicated)
G. AFTER CARE
1. Puts patient in a comfortable position
2. Does after care of all articles and equipment used
H. DOCUMENTATION
Documents the procedure and all deviations
Score = (No. of YES) / 39 x 100 = _____%
___________________________ ___________________________
- 95 -

Level 4 Modules For Nursing Skills Audit

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Level 4 Modules For Nursing Skills Audit

Uploaded by

Copyright:

Available Formats

FAR EASTERN UNIVERSITY

MODULE 1: ASEPTIC TECHNIQUE

Sterile technique is essential to help prevent surgical site infections (SSI), an

Principles of Surgical Asepsis

Principles of Sterile Technique

• Hand hygiene is a priority before any aseptic procedure.

• When performing a procedure, ensure the patient understands how to prevent

• Choose appropriate PPE to decrease the transmission of microorganisms from patients

Steps Additional Information

Commercially packaged sterile supplies are marked

Check packages for sterility by assessing intactness,

Sterile objects must only be touched by sterile

Whenever the sterility of an object is questionable,

Never turn your back on the sterile field as sterility

Set up sterile trays as close to the time of use as

Stay organized and complete procedures as soon as

Sterile objects can become non-sterile by prolonged

6. Any puncture, moisture, or tear that

7. Once a sterile field is set up, the

8. If there is any doubt about the

The front of the sterile gown is sterile between the

Do not place non-sterile items in the sterile field.

Do not sneeze, cough, laugh, or talk over the sterile

Maintain a safe space or margin of safety between

Refrain from reaching over the sterile field.

When pouring sterile solutions, only the lip and inner

COVID 19: Considerations for Optimum Healthcare workers’ Protection Before,

In this section, the following issues are addressed.

1. Use of Personal Protective Equipment

• Negative pressure operating rooms and/or anterooms when available are

3. Specific Operative Risk Issues

4a. After operation/Recovery

obtain their perspectives on behavior following separation from the patient.

Surgical Hand Scrub

Types of surgical hand scrubs

Jewellery harbours microorganisms.

1. Remove all jewellery.

Hand hygiene with ABHR

6. Turns tap on, regulate the flow and

10. Removes the sterile brush and nail stick,

11. Lathers fingertips with sponge-side of

Scrub one hand and arm completely before

16. Scrub the arms, using an up-and-down

Checklist: Entering the OR

Steps Additional Information

This step prevents the need to unnecessarily leave the

3. Artificial nails should not be worn,

4. Remove all jewellery. Wedding

5. Don surgical attire (top and

Shoe covers will protect work shoes from accidental

Surgical hand scrubs reduce the bacterial count on

Mask must cover nose, mouth, and chin for a proper

A non-sterile person should stay at least one foot away

Continuation of the Procedure – GOWNING

NURSING SKILLS AUDIT

Surgical Handwashing / Gowning / Gloving

Name : ______________________________________ Score: ___________________

OFFERING THE GOWN

Score = (No. of YES) / 35 x100 = _____%

MODULE 2a: INTRAVENOUS INSERTION

Common Types of IV Solutions:

Considerations in the Selection of the Site

2. Solution should be sterile and in proper condition

Name : ____________________ Score: _

Name : ____________________ Score: _

Name : ____________________ Score: _