GENERAL PROCEDURES

1. ASSESSSING TPR & BP

2. OXYGEN ADMINISTRATION

3. NURSING DOCUMENTATION

4. STEAM INHALATION

5. HAND WASHING

6. TEPID SPONGING

7. STIZ BATH

8. PERINEAL CARE

9. EYE CARE

10. ORAL HYGIENE

11. CARE OF DENTURES

12. BED MAKING FOR OCCUPIED BED

13. TRANSFERRING PATIENTS

14. PATIENT SAFETY

15. APPLYING RESTRAINS

16. ORAL MEDICATION ADMINISTRATION

17. HAIR CARE

18. ISTILLATIONS OF EAR DROPS

19. ISTILLATIONS OF EYE DROPS AND OINTMENTS

20. SUPPOSITIORIES IN RECTUM

21. NASAL SWABS

22. SPUTUM COLLECTION

23. COLLECTION OF BLOOD SAMPLE

24. APPLICATION OF VAGINAL CREAMS

25. URINE SAMPLE COLLECTION

26. 24 HOURS URINE SPECIMEN

27. TAKING A THROAT SWAB

28. WOUND DRESSING

29. INSERTION OF NG TUBE

30. NG ASPIRATION

31. GASTRIC LAVAGE

32. URINARY CATHERIZATION (FEMALE)

33. URINARY CATHERIZATION (MALE)

34. USE OF INHALER

35. NEBULIZATION

36. TPN

37. CARE OF DRAINS &TUBES

38. PREVENTION OF HAPU

39. BLADDER IRRIGATION

40. ENEMA

41. BED PAN OFFERING

42. BLOOD TRANSFUSION

43. SUBCUTANEOUS INJECTIONS

44. INTRADERMAL INJECTIONS

45. INTRAMUSCULAR INJECTIONS

46. IV CANNULATION
47. CARE OF PATIENT WITH TRACHEOSTMY

48. SUCTIONING

49. PREVENTION OF NOSOCOMIAL INFECTIONS

50. CARE OF VALUABLES

51. CARE OF DYING PATIENTS

52. CARE OF COMTOSE PATIENTS

ASSESSMENT OF VITAL SIGNS: TPR, BP:

Objective
To ensure that a patient’s vital signs, i.e. body temperature, pulse rate, respiration and blood
pressure are monitored and measured accurately. The patient’s pulse and respiration rates
provide a baseline for evaluation, to help monitor the patient’s response to therapy and help
assess the patient’s cardiovascular and respiratory status. Blood pressure measurement aids
in the assessment of the patient’s arterial pressure, hemodynamic status and response to
therapy. Arterial blood pressure measure only if the patient has an arterial line

BODY TEMPERATURE:

Axilla Route:

Equipment:

 Digital Thermometer
 Alcohol swab
 Ensure that the patient is at rest. If the patient has just had a hot or cold drink or a
bath/shower, take temperature half an hour late

Procedure:
 Put the digital thermometer on mode
 Place the Digital thermometer under patient’s axilla /rectum
 Leave digital thermometer in place
 Take pulse and respiration during this time.
 Remove thermometer when it gives beep sound and note temperature and wipe off with
alcohol swab
 Replace thermometer in container
 Record temperature, pulse, respiration on the patient’s clinical chart/ spo2 monitoring/
master chart
 Report any abnormal or significant changes in temperature, pulse, respiration
PULSE:
Equipment:
A watch with a second hand

Procedure:
 Ensure that the patient is comfortable and relaxed.
 Place the first two or three fingers on the anterior aspect of the wrist laterally over the
radial pulse site
 Apply moderate pressure and feel the pulsation of the radial artery.
 Note the rhythm, volume, tension before counting the pulse rate for one minute
 Report and record

RESPIRATION:

Procedure:

 Take the patient’s respiratory rate while the finger is still in position after counting the
pulse. Note rise and fall of the patient’s chest with each inspiration and expiration
 Note the rhythm, and depth of respiration.
 Count the number of respiration for one minute
 Report and record for any abnormalities
BLOOD PRESSURE:

Equipment:

 Sphygmomanometer – electronic with appropriate size cuff

 Stethoscope
 Alcohol swab

Procedure:

 Have patient in a comfortable position – either lying or sitting

 Expose patient’s upper arm and remove any constricting clothing.
 Extend patient’s elbow and support arm with palm turned upward externally rotated to
expose the brachial artery on inside of elbow
 Apply cuff ensuring it is empty of all air and placing centre squarely over brachial artery.
Wrap cuff firmly around the arm and secure.
 Position mercury manometer so that bulb is level with patient’s heart and arm
 Record systolic BP by palpitating radial pulse
 Place stethoscope in operators ears and diaphragm over brachial artery and inflate cuff
to a point between 10 to 30 mm Hg above point where pulse is no longer audible
 Release cuff slowly by gentle release of screw allowing mercury pressure to fall
 Listen for first sound systolic pressure and note on mercury column of manometer (at
eye level) continue to release cuff pressure slowly until last manometer (at eye level0).
Continue to release cuff pressure slowly until last sound (diastolic pressure) is heard.
 Release remaining air from cuff and remove. Roll up neatly.
 Record reading and report any significant change in blood pressure.
 Wipe stethoscope, ear pieces and diaphragm with an antiseptic swab
 For pediatric patients check the Bp in lower limbs
OXYGEN ADMINISTRATION

Objective
To ensure that oxygen is administered at the prescribed rate/concentration

Equipment:
 Oxygen source
 Nasal cannula/nasal prongs, face mask, hood
 Humidifier
 Sterile water
 Flow meter Container with water(sterile )

Procedure:
 Explain therapy to patient
 Position patient as advised
 Assemble and connect oxygen flow meter, humidifier with water added (if
prescribed/indicated), tubing and oxygen delivery system e.g. cannula, catheter, face
mask
 Check entire delivery system for proper functioning, adjust oxygen flow rate to that
prescribed and fix delivery device to patient
 Nasal prongs/cannula: position with concave surface against floor of the nostrils, loop
tubing over ears and adjust ring under the chin.
 Face mask: Hold close to patient’s face for a few seconds before applying. Place
mask over patient’s nose and mouth, mould the nose clip to give a good seal and
position elastic strap around back of patient’s head
 Secure tubing to clothing or bed linen
 Instruct patient to breathe normally
 Record and report the effects of oxygen therapy, delivery rate and equipment used
 If patient needs to shift fro any investigations with oxygen ( in stretcher) make sure
flow meter sterile water should be minimum, not maximum
NURSING DOCUMENTATION

Purpose:
To ensure that there is a legible and accurate record of all patient care, treatments,
observations and that these are documented in a standard and concise format proving a true
reflection of the patient’s health care status throughout the period of hospitalization.

Procedure:

General requirements:

 Only blue or blue ink should be used on nursing forms/records, unless otherwise
specified.
 Identify all nursing forms/charts with the patient’s name, doctor and registration number.
As far as possible, use a patient sticker for the purpose. If the form/chart is double-sided,
both sides are to be used.
 Only Staff nurses are to make entries in nursing records.
 Where signatures or initials are required, use standard signatures or initials as per those
indicated on the specimen signature/initial record maintained at each ward/department.
 All written entries should be legible and in English.
 No white-out or highlighter pens are to be used, nor any entries erased.
 As far as possible, all entries must be made by the nurse giving the care.
 Nursing admission assessment should be round it up

Nurses Daily Assessment :

 Daily assessment of patient is done every shift by Staff Nurses at 7am,2pm &9pm
 Assessment is done based neurological condition Airway, Oxygen requirement,
Drains, hygiene, skin, urinary status, activity, diet, restrains if applied and safety
issues
 Alternative assessment can be done system vise by doctors
 The staff nurse doing the assessment must put the signature at the entry of
assessment in nurses records
Nursing care plan/ care given
 The purpose of Nursing Care Plan is to maintain a descriptive record of care given to
patients throughout their hospitalization and their response to the care
 A continuous written report is to be maintained for all patients in the Nursing Care Plan
form
 The Nursing Care Plan should briefly and accurately describe the time and reason for
admission, the treatment given and the patient’s response to same, abnormal
parameters and patient status.
 Parameters to be sent and medication administration are to be recorded in the Nursing
Care Plan.
 When making an entry, use standard signature and include designation. The time when
the entry is made should be entered. Enter the date only once every 24 hours
commencing with the first entry. And each new page/ side of nurses note record should
start with date & time
 Do not leave blank lines in the Nursing Care Plan. Fill incomplete lines with a straight
line
 Record date and time of discharge as well as patient’s status at the time in the Nursing
Care Plan.

Clinical chart:
 Use the Clinical Chart to maintain a record of patient parameters throughout his/her
period of hospitalization
 All inpatients are to have a clinical chart
 Record patient’s routine temperature, pulse, blood pressure, bowel movements, height,
weight Morse fall risk assessment, Braden scale pressure risk assessment.
 Use dots joined by straight lines to record pulse, temperature and respiration.
Inpatient medication chart:
 Use an Inpatient Medication Chart as a written prescription for all medications and IV fluids
to be administered, as well as a record of those already administered
 Use an Inpatient medication chart for all patients on medication or IV therapy
 Notify any abnormalities to physician
 Doctor to prescribe medications directly on the Medication Chart. However, in an
emergency, Staff Nurse can take a verbal order and document in Nursing care plan. In
such a situation, the doctor must write the order within 24 hours.
 Doctor’s written prescriptions must be legible and should include the name of the
medication, dose, route and frequency of administration. After administering the medicine
staff nurse will do initial signature.
 For any allergy of drug mentioning in allergies column
 Make the doctor to write the medication reconciliation box

Fluid Balance Chart:

 Use the fluid balance chart to maintain a record of patient’s fluid balance status those on IV
therapy of tube feeding, patients with wound drainage bleeding /Haemorrhage, ascites,
hyperpyrexia, gastroenteritis, cardiac or renal disorder etc on as per order
 Maintain this chart for post-operative and post delivery patients until the patient is able to
retain fluids without vomiting and until they have passed urine normally, both in terms of
quantity and without undue discomfort.
 All patients in critical care areas are to maintain strict intake and out put chart
 Similarly record blood transfusion amounts as also the quantum of fluids infused through
CVP or other peripheral lines.
 24 hours intake/ out put to be maintained

Discharge check list

 This is a reminder sheet and record of final instructions being given to the patient/patient
party. It is to assist both nursing staff and patients to ensure that all records, instructions,
medications and doctor’s reports are handed over as necessary.
Consent
 If patient unable to give consent for procedures or provide medical history, arrange for one
family member to wait with patient until doctor has visited patient
 Provide patient/relative with reassuring explanations of all procedures carried out and
anticipated plan of care.
 Affix identity band to patient’s arm
 Consent must be taken by during treatment
 Validity of consent from can be maintained
STEAM INHALATION

Objective
To ensure that the administration of drugs as a vapour reaches the respiratory tract in a
therapeutic dose

Equipment:

 A tray containing :
 Bowl
 Nelson’s inhaler (Disposable)/ inhaler- steamer
 Towel
 Medication (if prescribe)
 Mouthwash
 Tissue paper, cotton balls
 Sputum Mug
Procedure:

 Explain the procedure to the patient

 Arrange the articles of inhaler
 Observe the patient and put off the fan
 Pour the hot water till half of the inhaler
 Wrap the inhaler with a cover/towel (if disposable not required)
 Keep the inhaler in a bowl (if disposable not required)
 Take the inhaler to the patient.
 Place patient in a comfortable position.
 Position over-bed table in front of the patient, adjust the height and place inhaler on
the table making sure that the air-inlet faces towards the patient
 Keep tissue paper and sputum mug within patient’s reach.
 Instruct patient to breathe in through the mouth and breathe out through the nose.
 Continue inhalation for 15 to 20 minutes.
 Give a warm mouth-wash if required
 Report and record procedure
TEPID SPONGING

Objective
To decrease elevated body temperature through the process of evaporation, conduction and
convection.

Equipment:
 Basin of water
 Flannels or gauze pads (6 to 8)
 Bowl of ice cubes
 Bath towel
 Bed sheet
 Gown

Procedure:
 Explain the procedure to the patient
 Remove patient’s blanket
 Cover patient with a bath towel and remove gown
 Sponge and dry face.
 Moisten flannels in cool water and apply cold compresses to forehead, neck, axilla
and groins and change frequently
 Sponge patient’s body using long, downward sweeping strokes. Leave a film of water
on the skin
 Add ice cubes to basin of water as often as necessary to help keep water cool. Turn
patient and wet sponge back and buttocks.
 Duration of sponging should be for 15 – 20 minutes
 Pat the patient dry, change bed linen and gown
 Check patient’s body temperature half an hour later and record on Clinical Chart.
 Observe report on and record effectiveness of procedure in nurse note
SITZ BATH

Objective
To ensure comfort and relief following surgery, trauma or injury to peri-anal region and to aid
healing

Equipment:
 Basin ( big)
 Warm Water with prescribed solution
 Dressing set or gauze /pads
Procedure:
 Explain the procedure to the patient
 Fill basin half full with warm water
 Place basin on low stool or on floor
 Have patient sit in the basin for 10 to 15 minutes.
 Have an attendant with patient throughout.
 Dry and inspect the area and apply and fit sterile dressing,
 Assist patient back to bed
 Report and document the procedure, including wound status
EYE CARE
Objective
To ensure that the eyes are cleansed properly

Equipment:

 Sterile pack with cotton balls and gauze pads

 Normal saline
 Medications if required
 Safe touch disposable gloves
 Disposal bag

Procedure:
 Explain procedure to patient and position such that the procedure can be conducted
comfortably
 Wear the safe touch gloves
 Moisten cotton swab in the saline solution and wipe the eye from the inner to the
outer canthus
 Discard swab.
 Use a fresh swab each time and continue with eye care until eye is clean.
 Apply drops, ointment and/or pad as prescribed
 Record procedure in nursing care plan
ORAL HYGIENE

Objective
To ensure that teeth, gums and mouth stay clean and healthy and to freshen the mouth.
Equipment:
Tray containing:
 Gauze squares
 Swab Sticks
 Forceps (artery)
 Forceps (non-toothed dissecting)
 Mouthwash solution
 Containers for mouth wash and dentures
 Kidney tray
 Protective equipment
 Additional equipment ( tongue depressor or mouth gag in case of unconscious
patient)
 Disposal bag
 Water
 Vaseline
Procedure:
 Explain the procedure to the patient
 Place patient in sitting/ semi-recumbent / lateral position.
 Remove dentures, if any, and place in container, to be washed.
 Dip swab stick/dressed artery forceps into the mouth wash solution
 Clean mouth in the following sequence: lips, teeth, buccal cavity, palate and the
tongue
 Use each swab once only.
  Apply Vaseline to the lips, if required
 Inspect, record and report condition of the mouth
 Record the procedure care given in nurses note

BED MAKING FOR OCCUPIED BED

Objective
To ensure that beds are made causing minimal discomfort to the patient occupying the bed.

Equipment:

 Bed sheets -2
 Blanket
 Pillow cases
 Draw sheet/ cozy sheets
 Soiled linen bag and carrier

Procedure:

 Provide the privacy for the patient

 Loosen the old bed linen
 Adjust patient’s pillow and turn him/her to one side
 Keep the side rails down at other side
 Roll soiled draw or cozy sheet, protective sheet and bed sheet separately towards the
patient’s back
 Place the clean, folded sheets lengthwise along the patient’s back.
 Straighten bed sheet and tuck in the free ends of the sheet firmly and neatly with mitred
corners.
 Place clean protective sheet and draw in position. Tuck in free ends firmly & keep the
side rails up
 Keep the side rails down and Adjust pillow and assist patient to roll gently on to other
side
 Remove soiled linen by folding each item into a bundle with soiled side turned in.
 Discard each item separately into the soiled linen bag carrier
 Unfold the clean sheet over the edge of the mattress and tuck in free ends neatly and
firmly. Also unfold the protective and draw/cozy sheet and tuck the free ends firmly under
the mattress keep side rails up
 Assist patient to the desired position
 Change pillow cases.
 Remove soiled top sheet, replace with clean sheet and blanket, if necessary
 See that the bed-side table and locker are straight. Keep bed in a straight position and
ensure brakes are locked.
 Push bed screen back.
 Place call bell within easy reach.
TRANSFERRING OF PATIENTS
Purpose:
To ensure a smooth flow of information and care for all patients, who requires to be
transferred from one ward or department to another, within the hospital.

Equipment:
 Bed
 Wheel chair
 Stretcher

Procedure:
 Request for bed transfer
 Ensure that the doctor in-charge is aware of the transfer (if patient is being transferred for
medical reasons, doctor will have given the order)
 Advise patient/next of the transfer, explain reason for transfer, and give details of the
new ward, bed, date and time of transfer
 Ensure that the receiving ward/department is aware of transfer and any special
care/equipment required. Also ensure that a bed is ready and available.
 Update all nursing records and ensure that all medical records are intact and complete
 Pack patient belongings, medications, X-Rays and other therapeutic equipment in blue
bag and keep it ready.
 Ensure that patients’ condition is stable for transfer. If very unstable ensure a doctor is
available
 Keep appropriate mode of transport for transfer e.g. a wheel chair or transport trolley, as
well as any other assistance that may be needed, ready
 Accompany patient to transfer ward department and assist in the setting into new bed/room
 Refer to patient’s medical/nursing records to give verbal report of patient’s condition,
current treatment/medication regimes to nurse in-charge/ concerned nurse in receiving
department/ward
 Complete transfer slip/enter transfer details into own ward computer
PATIENT SAFETY

Purpose:
To ensure specific measures are taken for patients’ safety and that all patient injuries
/accidents are reviewed.

Procedure:

Bed/Trolley Rails:
 At all times when the patient is unattended on a bed or trolley, the side rails will be fixed in
the ‘up’ position.
 Patients on trolleys without side rails are not to be left unattended.

Bed/Trolley Brakes:
 Bed/trolley brakes will be kept locked whenever the bed/trolley is not being moved.
 All patients will have an identification band which for adults will normally be affixed to the
right arm unless otherwise indicated. The identification band will have the patient’s name,
UHID, age, sex, for newborn identification band will contain Mother’s name, UHID of
baby, age and sex.

Post-operative/Delivery Care :
 All patients ambulating for the first time after surgery/delivery will be accompanied by a
Staff Nurse or physiotherapist

Call Bells:
 All patients will have their call bell within reach and will have been instructed in its use.
Patients in bed will have their call be secured to their pillow. All steps will be taken to ensure
that all call bells are answered within three minutes (maximum).
 Use call bells in wash rooms

Patient Falls:
 All patient falls will be recorded in the Nursing care plan and on a patient incident form.
Specific measures will be taken to reduce the possibility of a subsequent fall and these
measures will also be recorded on the Patient Incident form .Patients at risk of fall as per
their diagnosis, medication therapy will be provided every support and assistance when
moving from the bed/chair/trolley and/or ambulating by a member of the nursing team.
These patients will also be advised of the need to call for assistance whenever they wish to
move from one place to another.

Spillages/Wet Floors:
 Spillages and wet floors will be mopped dry as soon as possible. Patients will be advised of
all areas of spillage/wet floor and will be asked not to walk in that zone until the spillage
has been cleaned and dried

 Sign boards to be kept in wet floor

Patient injury/Accident:
 All patient injuries/accidents will be immediately reported to the nurse-in-charge and, as
necessary, to the doctor. First aid and subsequent care will be given according to any
injury sustained. To complete incident form and submitted to quality office after signing
by nurse in charge will go to nursing director ,MS, for analysis

Vulnerable patients:
 Patients ≤ 16 years and ≥ 65 years physically/mentally challenged, any patient who
cannot perform activities of daily living, all ICU patients, terminally ill patients, dialysis
patients, patients undergoing chemotherapy, women in labor, patients suspected of
abuse/ victims of abuse.
 Patient first program, yellow band
 Risk assessment and re assessment
ORAL MEDICATION ADMINISTRATION

Objective
To ensure that the correct medication is given to the correct patient via the correct route.

Equipment:
A medicine tray containing:
 Ounce glass/ medication cup
 Medicine
 Medication chart
 Tissue
 Crusher if applicable
 Butter paper

Procedure:
 Carry the tray to the patient’s bedside.
 Check the patient identity to receive the medication by asking the
patient his/her name verbally and the identification band for UHID and
IP No
 Explain the reason for giving the medication before administering
 Check the order in the medication chart for 7 rights
 Right patient
 Right drug
 Right dose
 Right time
 Right route
  Right reason
 Right documentation
 Open the tablet by two fingers and drop in the medication cup and give it to the
patients
 Never handle the table in your hands
 Give the patient water to drink
 Always patient have to take medication in front of Staff Nurse
 Chart it down in the medication chart and sign it in the box given below with initial sign
 Carry the tray to Clean Utility Room and replace medication chart in place
 Wash the used item with soap and water and dry thoroughly
 Clean, dry and replace the tray with all the equipment
 If crusher is using use butter paper in between the medicine and crusher
 Assess / monitor the patient after giving medication for any allegoric reactions
APPLYING RESTRAINS:

Purpose:

To ensure that the use of restrains is clinically appropriate and in adequately justified
situations

To ensure that the use of physical restrains are used only when the patients behavior or
actions can harm of self or others

To ensure that the hospital staff understands and comply with the safe applications and
principles of the appropriate use of restrain devices

Physical restraint: refers to any physical method of restricting a person’s freedom of

movement, physical activity or normal access to his or her body

Physical restraints include:

Articles that keep the body immobile in a bed or trolley

Restraint does apply to:

 Medical protective devices (eg splint applied to a fracture extremity, table top chairs,
seat belts and bed rails
 Medical immobilization (eg surgical positioning , IV arm boards, protection of different
sites by bulky dressings in pediatric patients
 Radiotherapy procedures

Order:
  A physician order is necessary for restraint use and consent has to be taken by
doctors every 24 hours
 The order must state the reason, type and time period for use
 New orders must be rewritten if restraining therapies are to be continued

Assessment:

 Assessment of patients must be done before making the clinical judgment to apply
restrains
 Assessment should include
 Behavior cognition or reason that requires the use of restrains
 Cognitive ability of the individual
 Patients must also be assessed to determine whether treatment of an existing
problem would obviate the need for restrain use
 After the original order expires, the patient should be reassessed by a clinician

Monitoring:
 Patients on physical restraints must be monitored for complications from the restraints
every 2hours
 The need for nutrition, hydration, elimination, circulation, physical and psychological
status and comfort of the patient should be addressed during restraint and document
it.

Documentation:
 The assessment of the need for restraints and clinical justification for use
 The type of restraint
 The findings of ongoing monitoring of the patient for complications.
 Education of the patient and significant others about restraint use.

Indications for the use of restrains:

  To decrease the risk of deliberate or inadvertent removal of an essential medical
device (e.g. circulatory assist devices, endotracheal tubes, tracheotomy tubes,
intracranial catheters, nasogastric or orogastric tubes, enteral feeding tubes, central
venous catheters, arterial catheters, chest tubes, surgical drains, intravenous lines
and urinary catheters) in Neurological cases etc.
 To limit the patient’s movements if movement might lead to a new or exacerbate an
existing injury (e.g. patient with a spinal fracture).
 To facilitate the performance of bedside procedures in patients who cannot cooperate,
to allow placement of the device and to ensure that the patient is not injured during the
placement (insertion of an arterial catheter in a delirious patient).
 Patients with potential to injure themselves or others (e.g. drug overdose, suicide
attempt).
 Measures promoting the child’s self-control or less restrictive options have failed or
are impractical

Restrains can be initiated based on patients assessed need:

 A Staff Nurse can initiate restraints use for a patient displaying the following
behavior/state - safety risk to themselves or others, acute confusion, dementia.
Restraints can also be initiated by a physician order.
 Patients must be assessed on the following on a regular basis
 Behavior
 Circulation Skin integrity of restrained body areas
 Restrained extremities for pressure-related injury

Release of restrains:
 Restrained patients must be checked / attended to, and reviewed for release
 Restraints should be removed at least every 2 hours “whenever possible” or “if the
harm is not imminent”, and more often if necessary, to allow for activities There must
be coordination of various members of the team before removing the restraints.
 Restraints must be easy to remove in case of an emergency.
HAIR CARE
Objective
To ensure that both the hair and scalp of bed-bound patients remain clean and healthy

Equipment:
 Container of warm water
 One small jug
 Shampoo
 Protective material/ cozy sheet
 Bath towel
 Face towel
 Bucket for soiled water
 Cotton balls to plug the ears

Procedure:
 Explain the procedure to the patient to gain the confidence of the patient
 Remove pillow and place bath towel under patient’s head and neck
 Plug the ear with cotton balls
 Tilt the rounded end of the rinser
 Place a bucket under the spount.
 Assess the scalp condition for any infection, injuries, bed sores etc
 Shampoo hair thoroughly massaging the scalp with finger tips. Ensure that the
shampooed water do not get into the patient’s eye and ears
 Remove excess lather and discard into the bucket
 Rinse hair thoroughly
 Squeeze excess water from hair.
  Place towel under nape of neck and dry hair with towel.
 Comb and dry hair with hair dryer if available
 Report any significant observations e.g. dandruff, condition of the scalp.

INSTILLATION OF EAR DROPS

Objective
To ensure the correct treatment of ear infections and to soften cerumen

Equipment:
 Cotton swabs
 Dressed applicators
 Ear drops, as prescribed
 Protective material/ cozy sheet
 Medicine dropper

Procedure:
 Position patient so that affected ear is uppermost
 Ensure that there is sufficient light.
 Check label for current drug.
 Open bottle cap and change the dropper
 Clean the discharge or wax.
 Instill two drops (ensure that the dropper does not touch the ear)
 Explain the patient that when instilling the ear drops patient will fell medicine taste in the
throat
 Apply gentle pressure on the tragus of the ear with finger
 Instruct patient to remain in the same position for 2-3 minutes and place the cotton swab
in the orifice of the ear.
 Report and record in the nursing notes
INSTILLATION OF EYE DROPS AND OINTMENTS
Objective
To dilate pupils for fundal examinations, to treat inflammatory conditions, to lubricate the
cornea, or to instill pre/post operative eye drops

Equipment:
 Sterile tray
 Prescribed eye drops/ointment
 Normal saline
 Bandages, eye shield
 Adhesive tape/ trans spore
 Scissors
 Disposal bag

Procedure:

 Allow the patient to sit with his head tilted slightly backwards or to lie in the dorsal
position.
 Check the orders and bottle or vial for the correct medication and correct
concentration, expiry date and discoloration
 Check the doctors order for instillation in eyes
 Remove eye pad if present
 Wash hands again before cleaning the eyes.
 Ask the patient to open both eyes.
 Pull the lower lid down gently towards the cheek with one hand and clean the lid if there
is any discharge
 Clean the eye from inner canthus outwards, using each swab once only
 Instruct the patient to look upwards
 Hold the dropper of the container about 3 cm from the eye and squeeze the dropper to
instill 1 or 2 drops into the centre of the lower fornix
 Ensure that the tip of the dropper/container does not touch the lower fornix
 Instruct the patient to close the eyelid gently, keep closed for a few minutes and then
open the eye once again
 Squeeze out required amount of ointment, apply on the lower fornix
 Wipe off excess ointment
 Apply a pad if necessary
 Report and record any pain, redness or tearing
SUPPOSITORIES IN RECTUM
Objective

To ensure that the suppository is inserted into the rectum correctly.

Equipment:

 Suppository
 Gloves
 Cotton balls
 Lubricating material / xylocaine jelly

Procedure:
 Place patient in the left lateral position with right leg folded at 45 degree angel
 Cover patient with a sheet exposing only the anus
 Put on glove
 Lubricate the gloved finger
 Remove suppository from foil wrapper
 Separate the patient’s buttocks with the other hand. Using the gloved index finger,
insert the suppository gently beyond anal canal, about 2.5 to 3.8 cm.
 Keep the finger inside for a few seconds to ensure suppository remains in situ, then
remove slowly.
 Direct patient to remain in the bed for 5 minutes.
 Wash hands.
 Report and record procedure and make a note of the result
NASAL SWABS

Objective
To ensure that nasal swabs necessary for the culture of pathogens are obtained through the
correct method.

Equipment:
 Nasal speculum
 Tissue paper
 Sterile dressed applicators
 Receptacle

Procedure:
 Explain the procedure to the patient
 Position the patient in upright position or dorsal recumbent position with his/her head
tilted backwards
 Insert the speculum gently or push the tip of the nose upwards
 Insert the swab and take the specimen required. Return swab into sterile container,
making sure that there is no contamination
 Allow patient to blow his/her nose.
 Ensure that specimen is correctly labeled and dispatch along with appropriate forms
 Report and record procedure.
COLLECTION OF BLOOD SAMPLE

Objective
To ensure that correct procedure applied when obtaining blood for testing

Equipment:
A tray containing
 Syringe 5 ml / 10 ml
 Alcohol swabs
 Vaccutainers
 Gloves
 Tourniquet

Sites for collecting blood:

 Antecubital area
 Wrist
 Dorsum (back) of hand
 Top of Foot

Procedure:
 Explain the procedure to the patient for the cooperation of the patient
 Wash hands and wear the gloves
 Instruct the patient to extend arm (the arm should be held straight at the elbow).
 Apply the tourniquet directly above the elbow with just sufficient pressure to make the
vein more prominent and easier to enter
 Inspect the area to visualize and palpate the vein
 Clean skin with alcohol swab and dry.
 Fix chosen vein with the thumb and draw the skin taut immediately below the site to
stabilize the vein before inserting needle.
 Hold syringe with bevel of needle uppermost, directly in line of the vein to be used.
Insert the needle quickly and smoothly under the skin and into the vein.
 Obtain blood samples by gently pulling back the plunger.
 Release the tourniquet as soon as specimen is obtained.
 Withdraw the needle slowly.
 Apply sterile gauze to puncture site and request patient to apply gentle but firm pressure
for 2 to 4 minutes.
 Take the blood sample from the needle as required.
 Remove the needle from the syringe and gently eject the blood sample into vacutainer
 Hold the vacutainer in a slanting position and allow the blood sample to coagulate, or
else, invert the vacutainer gently several times to enable the blood to mix with the
anticoagulant/reagent.
 Label specimen correctly and send to the laboratory immediately, along with the
Specimen Request Form.
 Destroy and dispose of needle and syringe in Sharps Container to avoid possible spread
of blood-borne viral diseases
 Dispose off gloves and wash hands.
APPLICATIONS OF VAGINAL CREAMS

Objective:
To ensure that vaginal creams used to treat genital tract infections and pelvic inflammatory
conditions.

Equipment:
 Sterile swabbing pack plus vaginal speculum
 Medication / cream
 Sponge holding forceps
 Sterile gloves (2 pairs)
 Procedure light/torch
 Waste disposal bag

Procedure:
 Screen the patients identity and explain the procedure
 Wash hands and wear the gloves
 Assist the patient to lie in the dorsal recumbent position
 Clean the vulval region
 Apply the cream in vaginal orifice
 Dry the vaginal area and put the pad
 Report and record procedure and sign in the medication chart
URINE SAMPLE COLLECTION

Objective:
To ensure that uncontaminated urine is obtained for microscopic examination.

Equipment:
 Sterile gloves
 Sterile kidney dish
 Sterile specimen container
 Bed pan/urinal

Procedure:
 Explain the procedure to the patient
 Provide privacy to the patient
 Allow patient to collect urine if he/she is able to.
 Ensure that patient is given detailed instructions
 Clean genitalia while patient is in bed
 Instruct patient to void small amount of urine into bed pan/urinal
 Collect mid-stream urine in the sterile container
 Remove bed pan/urinal.
 Remove gloves and wash hands.
 Label and send specimen to Pathology as soon as possible.
  Report and record procedure

24 HOURS URINE SPECIMEN

Objective
To ensure that the specific quantities of urinary constituents secreted with a designated
period are measured correctly and for the proper assessment of renal function.

Equipment:
 Specimen container (containing preservatives) as supplied by laboratory
 Urinal
 Bed pan and/or commode

Procedure:
 Explain the procedure to the patient
 Label container with patient details and date/time of commencement of the procedure
 Instruct patient/patient party that all urine passed must be saved throughout the
specified period if require health care attendant can help to collect.
 Advise patient to void and discard the initial specimen at the commencement of the
collection time.
 Measure and save all urine passed thereafter in the container and record output on
the Fluid Balance Chart
 Ensure that patient voids at the end of the designated period and that this specimen is
included in the collection
  Record the total amount of urine
 Dispatch a small specimen container of the urine collected to the laboratory indicating
the total amount collected and the collection commencement and completion times on
the lab request form

TAKING A THROAT SWAB

Objective
To ensure that the correct method is followed when taking throat swabs for the culture of
pathogens

Equipment:
 Sterile swab stick
 Wooden spatula
 Mouth wash
 Disposable bag

Procedure:
 Position the patient in an upright or recumbent position with his/her head tilted
 Ensure that there is enough light. Re-position lamp/light, if necessary
 Instruct patient to open mouth as wide as he/she can.
 Depress tongue with wooden spatula.
 Instruct patient to hold his/her breath.
 Collect specimen from the affected area without touching any other part of mouth
 Check that specimen is correctly labelled and dispatch along with appropriate forms.
 Clear away equipment. Wash hands.
  Report and record procedure

WOUND DRESSING
Objective

To ensure that patient wounds are protected from injury or contamination, to provide sterile
material for absorption of drainage and to apply medication.

Equipment:
 Sterile Dressing Tray
 Cleansing lotions/ normal saline
 Medication, if required
 Adhesive tapes/ transpore
 Counter scissors
 Disposable bag
 Protective material, ICU utility it/PPE/ cozy sheet
 Gown
 Mask
 Disposal bag (yellow bag)

Procedure:
 Explain the procedure to the patient
 Provide privacy to the patient
  Remove adhesive tape and other dressing
 Wash hands and dry
 Unfold the wrapper of the dressing pack without touching the inner side of the wrapper
 Wash hands thoroughly and dry
 Arrange instruments and dressing material appropriately. Instruct the assistant to pour
the required solutions
 Open the dressing pack
 Remove and discard the soiled dressing in yellow bag with a pair of dissecting forceps.
Observe wound for any signs of inflammation
 Discard used forceps into the used dressing tray

INSERTION OF NASOGASTRIC TUBE

Objective

To introduce a tube into the stomach via the nasal route to:
 Aspirate or decompress the gastrointestinal tract.
 To prevent or relieve abdominal distension
 Irrigate the stomach
 Administer feeds & medication
 Obtain a specimen of gastric content for analysis/examination

Equipment:
 Gauze piece
 Naso-gastric tube
 Water-soluble lubricant or xylocaine jelly
 Normal saline
 Glass of plain water
 Syringe 20 or 50 ml
 10 ml syringe fro aspiration
  Adhesive tape
 Scissors
 Clamp/spigot
 Disposable bag
 Stethoscope

Procedure:
 Explain the procedure to the patient
 Provide the privacy for patient
 Position patient comfortably in Fowler’s or supine position with Hyperextend head
and neck
 Measure the length of the tube to be inserted this is approximately the distance
from the patient’s ear lobe to the bridge of the nose and from the nose to the tip of
the xipoid process- 50 to 60 cms).
 Lubricate the tube before insertion
 Ask the patient to swallow when inserting tube in to stomach
 Pass the naso-gastric tube gently along the floor of the nose through the
nasopharynx and down the oesophagus into the stomach
 Offer patient sips of water (if permitted). When the tube has reached the back of
his/her pharynx, advance the tube as he/she swallows, through the oesophagus
into the stomach
 If the patient experiences any discomfort, withhold the tube a while, then direct
patient to close the mouth and inhale deeply. Rest a few seconds before passing the
tube further.
 Rotate the tube gently if there is any resistance. Do not force the tube if there is any
resistance or any obstruction
 Check position of the tube by aspirating a small amount of gastric content
 Placing a stethoscope over the epigastrum and then injecting 10 to 15 ml of air into
the tube and listen the gush sound with the help of stethoscope
 Secure tube with adhesive tape.
  Spigot the free end of the tube after insertion or attach to a drainage bag
depending upon the order
 Wash hands and clear away equipment
 Report and record procedure.

NASOGASTRIC ASPIRATION

Objective
To ensure that the correct method is followed to withdraw accumulated fluids or gas from the
stomach in order to empty gastric content at regular intervals.

Equipment
A tray containing
 Syringe (20 or 50 ml)
 Kidney tray
 Measuring jug
 Gloves

Procedure:
 Explain the procedure to gain the cooperation of the patient
 Provide the privacy for patient
 Elevate the head of the bed at 45 degrees if necessary
  Attach the syringe to the naso-gastric tube and aspirate gastric contents at specific
intervals as prescribed
 Pinch the NG tube and remove syringe ( see that air do not enter in the tube
 Suck the contents of the stomach
 Measure the amount of aspiration
 Save specimen for inspection if any abnormalities detected.
 Report and record the time, color and amount of aspiration on the intake-output chart
 Attend to the oral and nasal hygiene

GASTRIC LAVAGE
Objective
To remove ingested non-corrosive poisons or contents from the stomach

Equipment:

 Gastric lavage tube

 Lubricant
 Syringe (20 ml) if nasogastric tube is used
 Funnel
 Mouthwash for plain water and Listerine
 Required fluid (e.g. normal saline, sodium bicarbonate)
 Protective material
 Bucket for return fluid
 Specimen container
 Receptacle or container for dentures (if any)
 Suction apparatus
Procedure:

 Explain the procedure to the patient if he is conscious or to patient party

 Give the patient a glass of water to drink if he is conscious. This is to delay absorption of
poison in poisoning cases

 Remove dentures, if any.

 Position patient in the sitting or semi-prone position as his/her condition permits. If the
patient is unconscious, intubate with a cuffed endotracheal tube prior to the
introduction of the stomach tube.

 Lubricate the tube

 Insert the stomach tube via the oral route while maintaining the head in the neutral
position and ask the patient to swallow as the tube is inserted

 Hold the tube if the patient gags, proceed slowly by giving reassurance

 Aspirate the stomach contents and test with blue litmus paper before proceeding with the
irrigation

 Save the specimens.

 Elevate the funnel above the patient’s head and pour 200 to 300 ml of fluid into the
funnel

 Turn the funnel and the tube downwards before it empties completely to siphon the
gastric contents into a bucket.

 Repeat the lavage procedure 10 to 15 times until the return fluid is clear.

 Hold the gauze around the tube, pinch and withdraw it quickly and gently at the
completion of the lavage. Keep the patient’s head lower than the body while
withdrawing the tube to prevent the fluid from accessing the patient’s trachea.

 Observe and record quantity of the fluid (used and returned), and the character and
smell of the gastric contents
 Seal the specimens for the toxicological analysis

 Observe patient closely for vomiting, gagging, consciousness state

 Wash hands.

 Document total amount of stomach contents in the out put chart and nurses note.
URINARY CATHERIZATION (FEMALE)

OBJECTIVE
To ensure that the insertion of a urinary catheter is undertaken as an aseptic procedure

Equipment
 Sterile Catheter Tray
 Sterile Gloves
 Lubricant( xylocaine jelly)
 Cleansing lotion or betadine lotion
 Sterile Catheter (correct size for patient)
 Sterile water/ normal saline
 Draining bag/holder urinary bag
 Adhesive tape
 Cozy sheet
Procedure:

 Explain the procedure to the patient

 Provide the privacy to the patient
 Female patients will be catheterized by female staff nurse.
 Put on gloves Place patient in the dorsal position with thighs apart.
 For female patients, flex the knees
 Check the balloon using sterile water and lubricate the portion of the catheter to be
inserted.
 Drape and clean the labium majora, labiu minora, vulva perineal area and alteral side
of the thighs
 Place the whole towel in to perineum
 Introduce catheter into the urethra avoid touching any external surface
 When introducing catheter ask the patient to take deep breath
 Lubricate the catheter and insert into urethra
 Inflate the balloon with sterile water according to the amount marked
 Leave the drainage end of the catheter onto the receiver
 Fix catheter and the drainage bag properly to ensure no traction against the bladder
neck.
 Dry vulval area, remove all articles and make the patient comfortable.
 Instruct patient regarding catheter drag and position for drainage bag.
 Wash hands.
 Report and record procedure.
 Maintain fluid balance chart and encourage/advise patient regarding fluid intake
requirements
URINARY CATHERIZATION (MALE)

OBJECTIVE
To ensure that the insertion of a urinary catheter is undertaken as an aseptic procedure

Equipment
 Sterile Catheter Tray
 Sterile Gloves
 Lubricant/ xylocaine jelly
 Cleansing lotion or betadine lotion
 Sterile Catheter (correct size for patient)
 Sterile water (normal saline )
  Draining bag/holder urinary bag
 Adhesive tape
 Cozy sheet

Procedure:

 Explain the procedure to the patient

 Male patients may be catheterized by male staff nurse (if available), otherwise by male
doctor
 Put on gloves place patient in the dorsal position with thighs apart.
 Check the balloon using sterile water and lubricate the portion of the catheter to be
inserted.
 Drape and clean the penile area
 In male patients, insert the nozzle of a syringe containing lubricant (single use) into the
urethral meatus. Instil lubricant slowly
 When introducing the catheter in to the urethra ask the patient to take deep breath
 Introduce catheter into the urethra avoid touching any external surface
 Inflate the balloon with sterile water according to the amount marked
 Leave the drainage end of the catheter onto the receiver
 Fix catheter and the drainage bag properly to ensure no traction against the bladder
neck.
 Dry penile area, remove all articles and make the patient comfortable.
 Instruct patient regarding catheter drag and position for drainage bag.
 Wash hands.
 Report and record procedure.
 Maintain fluid balance chart and encourage/advise patient regarding fluid intake
requirements
USE OF AN INHALER

Objective
To ensure that the Inhaler is delivering medication in to the lungs

Purpose:
It is mainly used for treating asthma and COPD.

Equipment:

 Inhaler
 Tissue
  Sterile gauze peace
Procedure:

 Explain the procedure to the patient

 Remove mouthpiece cover

 Shake inhaler well for 2 to 5 seconds.
 Place inhaler (mouth piece) in between the teeth and seal with the lips.
 Take a deep breath and exhale completely
 Inhale slowly and deeply through mouth, depress medication canister fully.
 Hold his/her breath for 10 seconds.
 And take the breath normally
 Record the time when procedure was done and mention the name the medication
was used , observation made and patient’s condition during and after the procedure.

CARE OF DRAINS AND TUBES

Purpose:

To reduce the risk of further complications

Procedure:

 All wounds and drains must be handled under aseptic technique

 Continuous monitoring should be done for patients on drain
 All soiled dressing on wound must be checked and changed accordingly
  Check the patency of all drains.
 Wound dressing must be kept dry at all times and checked for soakage
 Observation of wound must be documented
 Proper hand over should be given to the concerned nurse about the type of drain
 Check connection area of the drain and fix it properly after surgery.
 Drains should be hanged outside to the cot of the patient for proper visualization

TOTAL PARENTRAL NUTRITION

Objective:

To provide nutritional requirement in patients who are unable to receive enteral feeding

Equipment:

 TPN request form

 TPN Bag
 Volumetric infusion pump
 IV administration set (used with infusion pump)
 Alcohol swab

Procedure:
 The nurse in-charge of the patient is required to Dispatch original copy of form to
pharmacy by 11.00 hours the same day.
 File the duplicate copy with patient's s case notes.
 For TPN schedule to be infused on Sundays/PH place orders and dispatch forms on
Saturday / the day before
 On receipt of the TPN.
 Check prescription of the bag label
 Check expiry date
 Store TPN bag in refrigerator after checking
 Leave TPN bag at room temperature for 1/2 hour before setting up.
 Ensure that the TPN bag is encased in the black bag provided by pharmacy.
 Calculate rate of infusion according to prescription. Maintain constant infusion rate
over 24 hour basis
 Ensure the correct TPN bag is put up by checking the label on the bag with patient's
identification band before administration
 Wash and dry hands.
 Prime the administration infusion set Use filter if required
 Swab three way adaptors on the central line with alcohol swab.
 Connect the administration infusion set to the central line
 Set the rate on infusion pump
PREVENTION OF HOSPITAL ACQUIRED PRESSURE ULCERS

Objective: To reduce the risk of HAPU

Skin Care &Back Rub

Back rubs should be given with every bed bath and more often. They are also helpful at
bedtime to promote relaxation and every time you reposition a patient who is unable to move
on their own. Back rubs are comforting, they promote blood flow to the back and they prevent
skin breakdown

Protocol in the hospital

 Take a mild body lotion/ preferably Vaseline lotion

 Wash your hands
 Wear gloves
  Place the person on their side and put the lotion on the palms of both hands
 Apply the lotion to the person's back
 Start at the bottom (buttock region) of the spine
 Use figure of 8 movements with long, smooth, gentle circulatory strokes move up to
and around the shoulders and slide down the sides of the back.
 Use the same movements as mentioned above for tapping and pinching
 Dedicate 2 minutes for circular massage cycle, 2 minutes for tapping and 2 minutes
for pinching

Materials to be used for back care

 Use a mild lotion to lubricate dry skin and to give back care to the patient
 Lotion helps to keep the skin healthy and soft.
 Preferably use Johnsons’ Baby lotion or Vaseline lotion only.
 In case of non availability of the above lotions, use any other branded mild skin
moisturizers/lotions or coconut oil approved by the Pressure ulcer team.
 Do not use alcohols or alcohol base lotions (alcohol dries the skin) as well as
petroleum jelly on skin

BLADDER IRRIGATION

CONTINUOUS BLADDER IRRIGATION (CBI)

A continuous infusion of a sterile solution into the bladder,

usually by using three-way irrigation closed system with a triple-lumen catheter. One
lumen is used to drain urine; another is used to inflate the catheter balloon, and the
final lumen carries the irrigation solution. CBI is primarily used following genitourinary
surgery to keep the bladder clear and free of blood clots or sediment

Purposes:
1. To cleanse the bladder
2. To maintain the patency of the urinary catheter
3. To prevent clot formation in case of bladder surgeries – Post surgically
 after prostatectomy
4. To prevent blockage of urinary catheter due to blood clot
5. For patients with severe hematuria as in Cancer of bladder and after TURP

Preliminary assessment in relation to:

Patient
1. Identify the patient and check doctor’s orders.
2. Asses the general condition of the patient.
3. Determine the type if solution to be used.
4. Assess the colour of urine and presence of mucus or sediment
5. Determine the type of catheter in place triple lumen or double lumen
6. Determine the patency of drainage tubing .
7. Assess the amount of urine in drainage bag

Equipment:
A clean trolley containing:
1. Sterile gloves
2. Irrigation Saline/Prescribed Solution
3. IV Set
4. IV Stand
Procedure
 Wash Hands.
 Explain the procedure to the patient.
 Identify the patient with two patient identifiers (Name and UHID Number) on the
patient’s ID Band
 Provide privacy to the patient.
 Assess the lower abdomen for bladder distension
  Position the patient in dorsal recumbent position or supine position. Drape the
patient appropriately.
 `Prepare the bladder irrigation solution as prepared for IV infusion.
 Using aseptic technique, insert tip of sterile irrigation tubing into bag of sterile
irrigating solution.
 Close clamp on tubing and hang bag of solution on IV stand.
 Open the clamp and allow solution to flow through tubing, keeping end of tubing
sterile.
 Close clamp.
 Wipe off the irrigation port of triple lumen catheter or attach sterile Y connector to
double lumen catheter and then attach to irrigation tubing.
 Ensure that the drainage bag and tubing’s are securely connected to drainage
port of triple lumen catheter or other arm of Y connector.
 For intermittent flow, clamp tubing on drainage system, open clamp on irrigation
tubing and allow prescribed amount of fluid to enter bladder (100 ml is normal
for adults)Close irrigation clamp, and then open drainage tubing clamp.(Optional:
Leave clamp closed for 20-30 min if ordered
 For continuous drainage, calculate drip rate and adjust clamp on irrigation
tubing accordingly. Ensure that the clamp on drainage tubing is open, patent
with no kinks and check the volume of drainage in the bag. Do not clamp the
irrigation tubing.
 Reanchor catheter to patient with tape or elastic tube holder.
 Assist patient to comfortable position.
 Lower bed to lowest position. Put side rails up if appropriate.
 The irrigation should be continued till the return flow is clear.
In case of post TURP, the procedure is continued for 24 Hours

After care of patient and equipment:

 Provide the patient comfortable position.
 The fluid used to irrigate bladder and catheter should be calculated and subtracted
from total output.
  Assess the characteristics of output: viscosity, colour, and presence of matter (e.g.,
sediment,clots, and blood)
 I f the output is less than the solution used for irrigation, the findings should be
reported.
 Assess for bladder distension and any blockage of tubing.
 Replace the equipment cleaned and dried.
 Remove gloves and dispose the contaminated articles and perform hand hygiene.

Documentation:
 Record the type and amount of irrigation solution used, amount returned as
drainage and the character of drainage.
 Record and report any findings such as complaints of bladder spasms, inability to
instill fluid into bladder, and /or presence of blood clots.

ENEMA
Definition

The term enema is used to refer to the process of instilling fluid through the anal
sphincter into the rectum and lower intestine for a therapeutic purpose.

Purpose
 To stimulate peristalsis (involuntary contraction) and to evacuate stool from the
rectum
 It dilates the bowel, stimulates peristalsis, and lubricates the stool to encourage
a bowel movement.
 To treat constipation, and reduce body temperature
 To evacuate intestinal parasites
  To cleanse the bowel before a bowel examination and before bowel surgery
 Oil retention enema is to soften the hardened stool and allow normal elimination.
 To deliver medication directly onto the rectal mucous membranes
 Steroid enema is administered to alleviate bowel inflammation in patients with
ulcerative colitis.
 Antibiotic enema solutions can be administered to treat localized bacterial infections.
 Medicated hypertonic enema solutions can be used to pull excessive potassium or
ammonia from the bloodstream through the rectal wall.

Indication
 Chronic constipation
 Orthopedic patient - on cast
 Neurological/psychotic disorder
 Preparation for surgery
 Before and after any radiological examination
 Before the normal labour

Preliminary assessment of client

Identify the client with two patient identifiers (Name and UHID Number) on the
patient’s ID Band
Check the doctor’s order
Assess the general condition of the patient
Assess the client ability to retain fluid

Equipment
A clean tray containing
 Disposable Enema can with tubing /Disposable enema like proctoglysis
 Pint measure
 Enema solution/ prepared enema
  Vaseline/xylocaine jelly
 Cozy sheet
 Gauze pieces in a bowl
 Kidney tray
 Glovesp
 IV stand

For immobilized patient

 Bedpan
 soap, clean linen
 Jug with water for perineal cleaning .

Environment
Provide privacy and well lighted and ventilated area

Steps of the procedure -soap and water enema

1. Wash hands.
2. Explain the procedure.
3. Cover the client with top sheet.
4. Remove the extra comfortable devices, and loosen the pajama.
5. Place the Cozy sheet under the clients buttocks.
6. Position the client in left lateral position with the buttocks close to the edge of
the bed and right knee flexed forward
7. Drape the client appropriately
8. Adjust the height of the iv stand to hold the enema can at the required height
9. Connect the enema can tubing’s and the rectal catheter
10. Attach the clamp to the tubing
11. Check the temperature of the solution and hang the can with the solution on the
stand
12. Wear gloves
13. Allow a small amount of the solution to run into the kidney tray by loosening
 the clamp.
14. Clamp the tubing.
15. Apply Vaseline /xylocaine jelly in rectal catheter with gauze piece for 3-4-
inches
16. Discard the used gauze into the kidney tray
17. Separate the client’s buttocks with a gauze pieces to visualize the anus clearly.
18. Instruct the client to take deep breath
19. Insert the rectal catheter for 3-4 inches directing it slightly upwards.
20. Hold the rectal catheter in place
21. Release the clamp and allow the solution to run it
22. Slowly flow the solution by lowering the can and advise the patient to hold
the buttock’s together.
23. After sufficient fluid is administered clamp the tubing and gently remove the
catheter and place it in the kidney tray
24. Instruct the client to retain the solution for 5-10 minutes, until there is a strong
urge to defecate
25. When there is a strong urge to defecate assist the client to toilet or provide bed
pan if client is immobile
26. Give the client a perineal toilet by using bed pan, clean and dry the skin
27. Remove the mackintosh &draw sheet and soiled linen
28. Remove gloves

After care of client and equipment

Make the client comfortable.
Clean, dry and replace the equipment in proper place.
Send the stool specimen to the lab if ordered for examination.
Wash hands
Record the time when the procedure was done ,observation made and client Condition

Disposable enema kit

Proctoclysis
Proctoclysis refers to the rectal administration of enema; it is a form of disposable enema.
Active Ingrediants
Monobasic Sodium Phosphate (19g). (a laxative/bowel cleanser)
Dibasic Sodium Phosphate (7g). (a laxative/bowl cleanser)
It is made up of Latex Free (prevents any allergic reactions with latex products)
A complete enema in a disposable squeeze bottle with a soft pre-lubricated comforted
tip

Advantages

It is a safe, effective and low-cost technique for the delivery of hydration in terminally ill
cancer patients, who do not have tumor involvement of the colon.
It does not need any sterile device or manipulation and can be delivered by family members
or other non-professionals, with minimal training.
For relief of occasional constipation or bowel cleansing before rectal examinations.

A BEDPAN / A URINAL CARE

Introduction

Bedpans and urinals are devices that allow a person in bed to urinate or have a bowel
movement (BM). A man uses a bedpan for having a BM but usually prefers to use a
urinal to urinate. Women usually use a bedpan for having BMs and urinating, but there are
also urinals made for women
Articles required
 A basin with warm water.
 Disposable gloves.
 Toilet paper.
 Towels.
 Wash cloths.

Elimination of urine
Procedure for assisting client in using a bedpan:
1. Wash your hands. Put on gloves.
2.Gather necessary equipment.
3. Explain what you are going to do.
4. Provide privacy.
5. Client should be in supine position (lying on his/her back); turn back top bedding.

Note: sprinkle water on bedpan to prevent sticking.

Client is able to assist.
a. Have client flex his knees and lift buttocks off mattress. Assist by slipping hand under
the lower part of his back. If client is wearing pajamas or underwear, lower them to his
knees
b. With your other hand, slip the bedpan under the client’s hips and adjust.
7. Client is unable to assist
a. Turn client on his/her side away from you.
b. Expose buttocks and position bedpan firmly against buttocks.
c. Place small pillow/rolled towel at top of bedpan at the small of client's back.
d. Turn client toward you and onto the bedpan.
8. Raise the head of bed or upper body (if allowed) for client's
comfort. Place toilet tissue within reach.
9. Remove and dispose of gloves.
10. Wash your hands and leave the room.

11. Return to room promptly when the client calls or check on him after five minutes
12. Wash hands. Put on gloves.
Placing a urinal for a male or a female
 The following steps may help when placing a urinal for a male or a female:
 Ask the person to put the urinal between the legs.
 Put on disposable gloves and spread the legs of the person if he cannot do it.
 If the person is male and he cannot do it, put his penis in the opening at the top of
the urinal.
 Position the urinal and hold it gently while the person urinates.
 When the person is done, carefully remove the urinal.
 Gently wipe between the legs with a damp washcloth. If the person is a female be
sure to clean from front to back.
 Dry the area between the legs of the person.

After carep
 Give the person a damp washcloth to clean his hands when finished with the
bedpan or urinal.
 Take the bedpan or urinal to the bathroom and empty it into the toilet
 Clean the bedpan or urinal with soap and water, and a toilet brush.
 Clean the bedpan or urinal as needed with a 2% hypo chloride or cleaning
solution. Ask caregivers to help you choose the cleaner.
 Use an air freshener if needed.

BLOOD TRANSFUSION PROCESS

Definition
Blood transfusion is the process of transferring blood or blood-based products
from one person into the circulatory system of another. Blood transfusions can be life-
saving in some situations, such as massive blood loss due to trauma, or can be used to
replace blood lost during surgery.
Purpose
Blood transfusions may also be used to treat a severe anemia or thrombocytopenia
caused by a blood disease/procedure/surgery. People suffering from hemophilia or
sickle-cell disease may require frequent blood transfusions. Early transfusions used
whole blood, but modern medical practice commonly uses only components of the blood.

Steps of administration

1. Appropriate order
2. Collection of patient sample for group and cross-match
3. Preparation and delivery of unit.
4. Identification of unit to the recipient.
5. Selection and proper use of equipment for transfusion.
6. Patient care during transfusion and maintenance of appropriate records.

Consent /order
1. Informed consent from patient or relative which is valid for 30 days
2. Risks, benefits and alternate therapy.
3. Written request for type of component along with cross match sample.
4. Special requirement for components.

Preparation and delivery of unit

1. Process of transfusion explained to patient, Identify the patient with name and
UHID
2. Venous access to be established.
3. Premeditations to be given.
4. Delivery of blood to patient area.
5. Identify the recipient and donor unit.
Equipment for transfusion
1. Needles and catheters
2. Infusion set -170 -260 microns.
3. Micro-aggregate filters.
4. Leukocyte reduction filters
5. Blood warmers

Patient care
• Time out at bed side
• Pre-transfusion vital signs recorded.
• Fill the transfusion record form.
• Delay in starting transfusion.
• Care during transfusion.
• Time limits for transfusion.
• Transfusion follows up.

Guidelines for recognition & management of acute transfusion reaction &

investigations.

Category –1: Mild reactions

Signs - Localized cutaneous Reactions like urticaria, Rash
Symptoms - Pruritus (Itching)
Possible Cause – Hypersensitivity (Mild)

Immediate Management
1. slow transfusion,
2. Administer Antihistamines IM

If no clinical improvement within 30 minutes or signs & symptoms worsen treat as category-2
Category – 2: moderately severe reaction
Signs:
 Flushing
 Urticaria
 Rigors
 Fever
 Restlessness
 Tachycardia
Symptoms:
 Anxiety
 Pruritis
 Palpitation
 Mild dyspnea
 Headache
Possible Cause
 Hypersensitivity (Moderate – Severe)
 Febrile non hemolytic transfusion reactions
o Antibodies to WBC’s , Platelets
o Antibodies to proteins including IGA
 Possible contamination with pyrogens and /or bacteria

Immediate management:
Start plan
1. Stop the transfusion.
2. Replace the infusion set
3. Keep IV line open with normal saline.
4. Notify the doctor responsible for the patient the blood bank immediately

Investigation plan

1. Send blood unit with infusion set,

 2. freshly collected urine
3. new blood samples (1 clotted & 1 anti coagulated) from
4. vein opposite infusion site with appropriate request form to blood bank for
laboratory investigations

Medical management
 Administer antihistamine IM (e.g. chlopheniramine 0.1 mg/kg or equivalent) & Oral or
rectal antipyretic (e.g. paracetamol 10 mg/kg: 500mg – 1 h in adults)
 Avoid aspirin in thrombocytopenic patients.
 Give IV corticosteroids & bronchodilators if there are anaphylactic features (e.g.
broncospasm, stridors).

Clinical follow up plan

1. Collect urine for next 24 hours for evidence of haemolysis & send to laboratory.
2. If clinical improvement, restart transfusion slowly with new blood unit & observe
carefully.
3. If no clinical improvement within 15 minutes or if signs & symptoms worsen, treat as
category 3.

CATEGORY -3: Life threatening reaction

Signs
 Rigors, Fever, Restlessness,
 Hypotension (fall of 20% in Systolic BP)
 Tachycardia (rise of 20% in heart rate),
 Haemoglobinuria (red urine),
 Unexplained bleeding (DIC).
Symptoms
 Anxiety, chest pain, pain near infusion site, Respiratory Distress/shortness of breath,
 Loin/back pain, Headache, Dyspnoea.

Possible Cause
  Acute intravascular haemolysis,
 Bacterial contamination & Septic shock,
 Fluid overload, Anaphylaxis,
 Transfusion Associated acute lung injury

Immediate management:
Start plan
1. Stop the transfusion. Replace the infusion set &
2. Keep IV line open with normal saline.
3. Infuse normal saline (initially 20-30 ml/kg) to maintain systolic BP.
4. If hypotensive, give over 5 minutes & elevate patient’s legs.
5. Maintain airway & give high flow oxygen by mask.

Medical management
 Give adrenaline (as 1:1000 solution) 0.01 mg/kg
 Body weight by slow intramuscular injection.
 Give IV corticosteroids & bronchodilators if there are anaphylactoid features (e.g.
bronco spasm, stridor).
 Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.
 Notify the doctor responsible for patients & blood bank immediately

Investigation plan
1. Send blood unit with infusion set, fresh urine sample &
2. New blood samples (1 clotted & 1 anticoagulated) from
3. Vein opposite infusion site with appropriate request form
4. To blood bank for investigations.

Clinical follow up plan

 Check fresh urine specimen for signs of haemoglobinuria.
 Start a 24-hour urine collection & fluid balance chart &
 Record all intake & output. Maintain fluid balance.
  Assess for bleeding from puncture site or wounds.
 If there is clinical or laboratory evidence of DIC,
 Give platelets (adults: 5-6 units) &
 Either cryoprecipitate (adults 12 units) or
 Fresh frozen plasma (adults 3 units).

Clinical reassessment
 If hypotensive:
 Give further saline 20-30 ml/kg over 5 minutes.
 Give inotrope, if available.
 If urine output falling or laboratory evidence of acute renal failure (rising K, urea,
creatinine)
 Maintain fluid balance accurately.
 Give further frusemide.
 Consider dopamine infusion, if available.
 Seek expert help: patient may need renal dialysis.
 If bacteraemia is suspected (rigors, fever, collapse, no evidence of a hemolytic
reaction), start broad-spectrum antibiotics IV

Transfusion reaction workup

BLOOD GROUP & Rh TYPE:
1. Patient’s pre transfusion sample……
2. Patient’s post transfusion sample………
3. Donor pilot tube sample……………
4. Sample from bag/bottle……………….

Compatibility testing
Patient’s pre transfusion sample & Donor pilot tube sample
Patient’s post transfusion sample & Donor sample from bag/bottle

Direct antiglobulin test:

 • Patient’s post transfusion sample
• Patient’s pre transfusion sample

Other investigations
1. Urine for Hemoglobin
2. Test for bilirubin
3. Culture for bacterial growth.
4. Anti IgA - patients serum if the reaction Anaphylactic

Records
 Records o f r e a c t i o n and workup to be maintained indefinitely for future
reference and for advice on the methodology for successful transfusion
subsequently.
 Fatal Transfusion reaction to be reported to FDA, case may warrant more
extensive inquiry
SUBCUTANEOUS INJECTION

Purposes:
To provide slower action of drug than intramuscular route when required

Equipments
1. Insulin syringe with needle
2. Tuberculin syringe with needle
3. Alcohol swabs
4. Vial/ampoule of medication
5. Disposable gloves
6. Medication chart

Administering medications in to the subcutaneous tissues

1. Assemble equipment
2. Check all 5 rights

3. Identify patient name, uhid number and explain procedure

4. Put on gloves, clean site
5. Pinch skin fat into fold of at least 1 inch
6. Insert needle at 90 degree anglep
7. Pull back on plunger, look for blood
8. Inject slowly
9. Withdraw and discard syringe
10. Monitor patient for effect

Documentation
Documentation to be done by the nurse in the medication record
INTRADERMAL INJECTIONS

Definition
Intradermal injections are injections given to a patient in which the goal is to empty
the contents of the syringe between the layers of the skin.

Purpose
Intradermal injection is often used for conducting skin allergy tests and testing for
antibody formation.

Precautions

 This is a painful procedure and is used only with small amounts of solution.
 The nurse should ensure that the needle is inserted into the epidermis, not
subcutaneously, as absorption would be reduced. It is imperative that the following
information is reviewed prior to administration of any medication: the right patient,
the right medicine, the right route, the right dose, the right site, and the right time.
 Because this method of injection is often used in allergy testing, it is important that
latex- free syringes are used.

Description
 With the intradermal injection, a small thin needle of 25 or 27 gauge and 3/8 to 3/4
inch (1-2 cm) is inserted into the skin parallel with the forearm, with the bevel
facing upward. These injections are normally given in the inner palm-side surface of
the forearm, with the exception of the human diploid cell rabies vaccine, which is
given in the deltoid muscle.
Preparation
1. Washing his or her hands,
2. Identify patient Name, UHID Number and explain procedure
3. Nurse should put on latex-free gloves to complete the procedure
4. A sterile syringe and a needle should be prepared. If a sterile multiple-dose vial is
used, the rubber-capped bottle should be rubbed with an antiseptic swab
5. The needle is then inserted through the center of the cap, and some air from the
syringe inserted to equalize the pressure in the container. Slightly more of the required
amount of drug is should then be removed.
6. The syringe should be held vertically at eye level, then the syringe piston should be
pushed carefully to the exact measurement line
7. If a small individual vial containing the correct amount of drug is used, the outside
should be wiped with an antiseptic swab and held in the swab while the top is snapped
off
8. The needle is then inserted into the vial, taking care that the tip of the needle does
not scratch against the sides of the vial, thereby becoming blunt.

The syringe and needle containing the drug should be placed on a tray with sterile cotton
swabs and cleaning disinfectant. If the patient is unfamiliar with the procedure, the nurse
should explain what he or she is about to do, and let the patient know that the medication
was prescribed by the doctor. As with all drugs prescribed for a patient, the dose on
the patient's prescript ion sheet should be checked prior to administration.

A screen should be drawn around the patient to ensure privacy. The injection site is
then rubbed vigorously with a swab, and disinfectant applied to cleanse the area and
increase the blood supply. With the bevel of the needle facing upwards, the needle is
inserted into the skin, parallel with the forearm. The syringe piston should then be
pushed in steadily and slowly, releasing the solution into the layers of the skin. This will
cause the layers of the skin to rise slightly.
Aftercare
Monitor the patient's reaction and provide reassurance, if required. Dispose of all waste
products carefully and place the syringe and needle in a puncture-resistant receptacle.

Complications
If the circulation is depleted, absorption of the drug administered may be slow.

Results
Check for any adverse reactions if the drug is being administered for the first time.

Documentation
 As this procedure is often used as a diagnostic tool, the process should be
explained fully to the patient.
 The health care team should record any side effects or negative reactions to the
drug that has been injected; medical staff should be notified and the drugs should
be changed.
INTRAMUSCULAR INJECTIONS

Objective:
The intramuscular route provides faster medication absorption than the subcutaneous
because of a muscle’s greater vascularity. The angle of insertion of Intra Muscular
injection is 90°.
Muscle is less sensitive to irritating and viscous medications.

Characteristics of intramuscular sites and indications for usage

 Vastus lateralis
Lacks major nerves and blood vessels
Rapid drug absorption
Preferred site for infants (less than 12 months) receiving immunizations.

 Ventrogluteal
Preferred site for medications (e.g., antibiotics) that are larger in volume, more
viscous and irritating for adults, children and infants.

 Deltoid
Not to be used in infants or children with underdeveloped muscles
Potential for injury to radial and ulnar nerves or brachial artery.
May be used for immunizations for toddlers, older children and adults.
Recommended site for hepatitis B vaccine and rabies injections.

Sites
Pre assessment
 The nurse assesses the integrity of a muscle before giving an injection.
 The muscle should be free of infection, necrosis, tenderness, bruising or abrasions.
 Repeated injections in the same muscle can cause severe discomfort.
 The volume of medication to be administered.
Ventrogluteal

 The site is located by placing the heel of the hand over the greater trochanter
of the patient’s hip, with the wrist perpendicular to the femur.
 The right hand is used for the left hip and the left hand is used for the right hip.
 The thumb is pointed toward the client groin and fingers toward the client’s head,
points the index finger to the anterior superior iliac spine, and extends the
middle finger back along the iliac crest form a V Shaped triangle, and the
injection site is the center of the triangle
 The client may lie on his or her side or back.
 Flexing of the knee and hip helps the client relax this muscle.

Vastus lateralis

 The middle third of the muscle is the suggested site for injection
 The width of the muscle usually extends from the midline of the thigh to the midline
of the thigh’s outer side.
 To relax the muscle the nurse asks the client to lie flat with the knee slightly flexed or
in a sitting position.

Dorsogluteal
 It is the traditional site for intramuscular injections. If the needle hits the sciatic
nerve, the patient may experience permanent or partial paralysis of the involved leg
therefore this site should not be used.

Deltoid
 The deltoid site is easily accessible and administers only small volume of
medication.
 To locate the muscle the Upper arm and shoulder of the patient should be
 exposed. The particular hand must be relaxed and elbows must be flexed.
 The lower edge of the acromion process is palpated, which forms the base of a
triangle in line with the midpoint of the lateral aspect of the upper arm.
 The injection site is the centre of the triangle, about 3 to 5 cm below the acromion
process.
 The site may also be located by placing three to four fingers across the deltoid
muscle; with the top finger along the acromion process. The injection site
is then three fingerwidths below the acromion process
 This site should not be used in children below 6 years

Equipment
A tray containing:
 Syringe and needle
 Alcohol swab
 Vial or ampule of medication
 Disposable Gloves

Procedure
 Review the five rights.
 Assess the history of any drug allergy.
 Check the date of expiry of the medicine.
 Assess for contraindication like muscle atrophy, reduced blood flow or circulatory
shock.
 Prepare the correct medication aseptically and be sure that all the air is expelled.
 Identify the patient with two patient identifiers (Name and UHID Number) on the
patient’s ID Band
 Perform hand Hygiene.
 Explain the procedure to the patient.
 Provide Privacy.
 Don the gloves.
  Select the appropriate site for injection and inspect the skin.
 Assist the patient to a comfortable position.
 Locate the site and swab the site from the center of the site and rotate
outward area in a circular direction about 5cm.
 Hold the gauze or swab between third and fourth finger of the non dominant hand.
 Remove the needle cap and hold the syringe between thumb and forefinger of
dominant hand, grasp the muscle between thumb and fingers.
 Insert the needle at 90° angle into the muscle slowly and gently. After needle
pierces skin, grasp lower end of syringe barrel with non dominant hand. Move
dominant hand to the end of the plunger. Do not move syringe.
 Pull back on plunger 5 to 10 seconds if no blood appears; inject medicine
slowly, at a rate of 10 sec/ ml.
 Wait for 10 seconds and then smoothly and steadily withdraw needle and release
skin.
 Apply Gentle pressure with dry gauze.

Documentation

 Record it in the medication chart and observe the site for any undesirable effects.
CARE OF THE PATIENT WITH TRACHEOSTOMY

Definition
A tracheotomy is a surgical opening in the anterior wall of the trachea just below the
larynx.It provides an alternative airway, bypassing the upper passages.

Purposes
The goals of tracheotomy care are to maintain the patency of the airway, prevent
breakdown of the skin surrounding the site, and prevent infection. Sterile technique
should be used during the procedure.

Types of tracheotomy
 Temporary
 Permanent
 Emergency
 Surgical
 Percutaneous
 Cricothyrotomy/ Minitracheostomy

Tracheotomy tubes
A tracheotomy tube is:
 Inserted through the tracheotomy to maintain a patent airway
 Secured in place by tapes tied around the neck

Types of tracheotomy tube

 Only for ET tubes cuffed and un cuffed
 Cuffed- portex
 duratwix

Bedside equipment
 Every patient with a tracheotomy tube should have the following equipment
available at the bedside:
 Spare tracheotomy tubes same size and type as patient is
wearing. Smaller size
 Tracheal dilator.
 Suctioning equipment
Tubing - change daily. Ensure equipment is assembled and working properly
Humidification Ensure equipment is assembled and working properly.
 Clean Gloves
 Sterile gloves (for suctioning)
 Infectious waste bag
 Dry clean container for holding the speaking valve, occlusive cap/button
or spare inner cannula when not in use.
 Natural rubber latex gloves to be used by all except those who have latex allergy.
 Duraodore, xylocaine jelly, sterile set

Procedure
(a) Identify the patient with name and UHID
(b) Wearing unsterile gloves remove and dispose of the soiled
dressing.
(c) Wash hands. Put on sterile gloves.
(d) First, remove and clean the inner cannula using sterile pipe cleaners and normal
saline. Dry. Reinsert.
(e) Secondly, clean the stoma site using gauze and normal saline. Pat dry.
(f) Lastly, if ties are soiled and need changing, have a second nurse hold the tracheotomy
tube securely in place, remove and replace tracheotomy ties. (g) Ensure patient comfort.
(h) Discard of used equipment as per hospital policy
(i) Wash Hands.
(j) Document procedure in the patient’s notes.

Care of the patient with a tracheotomy

DO ‘S
 Always keep supplies at your patient's bedside for suctioning; tube and stoma
care; delivery of oxygen, heat, and humidity; tracheotomy tube replacement; and
artificial ventilation.
 Begin assessing his tracheotomy by inspecting the stoma site, which is typically
slightly larger than the tracheotomy tube.
 Note the amount, color, consistency, and odor of tracheal and stomal
secretions. Confirm the tracheotomy tube size and whether it's cuffed or
fenestrated.
 When your assessment findings (coarse breath sounds, noisy breathing, and
prolonged expiratory sounds) indicate that your patient's airway needs clearing,
suction it using sterile technique.
 Hyperoxygenate him before and after suctioning and between passes to
compensate for suctioning- induced hypoxemia.
 If the inner cannula is designed for reuse, clean it in a solution of equal parts
hydrogen peroxide and 0.9% sodium chloride. Wear sterile gloves and maintain
aseptic technique. Remove encrusted secretions from the lumen of a metal tube with
sterile pipe cleaners or a soft sterile brush. For a plastic tube, use only sterile pipe
cleaners to prevent damage by a brush. After cleaning, thoroughly rinse the inner
cannula with 0.9% sodium chloride solution.
 Reinsert the inner cannula and securely lock it into place.
 Secure new ties to the tracheostomy tube flanges before removing the old ones.
Insert your little finger between the tie tapes and your patient's neck to check the fit
and ensure his
 Place a sterile split sponge under the tube flanges to absorb secretions.
  Place the call bell where your patient can easily reach it

DONT’S
 Don't clean and reuse an inner cannula designed for one-time use.
 Don't cut gauze and place it under the tracheostomy tube flanges; inhalation could
draw fibers into the patient's trachea. Use a manufactured split sponge.
 Don't lavage with 0.9% sodium chloride solution during suctioning unless you need
to clear blockage of clots or mucus.
 Don't allow a humidifier empty
 Don't let condensation accumulate in the oxygen delivery tubing.
SUCTIONING

Definition
Suctioning is a component of bronchial hygiene that involves the
mechanical aspiration of secretions from the nasopharynx, oropharynx, and trachea.
The airway may be in its natural state or artificial (as with a tracheostomy) or surgically
altered (as with a laryngectomy). The patient may or may not be receiving mechanical
ventilation

Purposes
 To remove accumulated pulmonary secretions

 To improve clearance of airway secretion

 To decrease the obstruction of airway
 To improve ventilation and gas exchange
 To remove blood and vomit’s in case of emergency situation

Types
 Endotracheal
 Oro pharyngeal
 Tracheal

Indications:
 Respiratory disorder/failure
 Neuromuscular disorder like myasthenia gravis,parkinsonian
 Loss of consciousness
 Impaired respiratory function
 Tracheostomy
 Stroke
 Suspected aspiration of gastric or upper airway secretions
 Visible secretions
  Congested-sounding cough

Contraindications:

 Bleeding disorder such as DIC,LUKEMIA, THROMBOCYTOPENIA

 Laryngeal edema, laryngeal spasm
 Esophageal varices
 Tracheal surgery
 Myocardial infraction
 Occluded nasal passages or nasal bleeding
 Epiglottis’s
 Head,facial,or neck injury

Assessment of need:
Health care personnel should assess the need for Endotracheal suctioning as a routine
and Identify the patient with two patient identifiers (Name and UHID Number) on the
patient’s ID Band

Articles needed
 Suction apparatus
 Disposable suction catheter
 Sterile disposable gloves
 Sterile water
 Specimen container
 Oxygen cylinder

Irrigants:
1. Saline
2. Sodium Bicarbonate
Optional
Equipment:
 ECG monitor
 Pulseoxymetry

Procedure

 Wash hands and apply personal protective equipment as indicated (gloves,

masks, gowns, eye protection)
 Adjust vacuum between -80 to -120mmHg for adults or -60 to -80mmHq for
pediatrics.
 Position the patient by extending the neck slightly to facilitate entrance into the
trachea
(Especially for nasotracheal suctioning).
 Open suction catheter exposing only the connector, attach to connective tubing and
maintain sterility of catheter.
 Fill sterile water in a sterile bowl in tracheotomy tray
 Check heart rate before, during and after procedure. If tachycardia or bradycardia
occurs discontinue the procedure until it resolves.
 Place sterile gloves on both hands.
 Remove suction catheter from envelope maintaining sterile technique.
 If patient has an artificial airway in place, hyperoxygenate with a resuscitation bag or
mechanical ventilator with 100% oxygen.
 If patient is receiving oxygen therapy, request several deep breaths
before suctioning.
 Insert the catheter through the nose or Endotracheal tube to the point of
restriction without applying suction.
 NOTE: do not aggressively force the tip of the catheter through any
obstructions in the nose. Withdraw the catheter and reposition the patient's
 head and try again
 After the restriction has been passed, slowly advance catheter. Ask patient to take
deep breaths or watch for inspiration. Pass catheter into trachea.
 Once catheter has been placed in trachea, slowly withdraw while applying
intermittent suction and rotating catheter.
 Remember: Suction should not be applied for more than 10-15 seconds.
 Hyperoxygenate the intubated patient or request the non-intubated patient to take
several deep breaths.
 Auscultate the patient's chest; if secretions can still be heard repeat the suctioning
procedure (5-
 10ml of normal saline may be used to loosen tenacious secretions). Before re-
suctioning, clear catheter with sterile water.

After care
 Discard gloves and catheters in an aseptic manner, clear connective tubing with
remaining sterile
 H20 and turn off suction.
 Return the patient to comfortable position.
 Discard personal protective equipment and wash hands.
 Document procedure as per department guidelines.
 Inform nurse and/or physician of any pertinent request, complaints or reactions to the
therapy.

Hazards/complications
 Trauma to the oral, tracheal, or bronchial mucosa;
 cardiac arrest;
 respiratory arrest;
 cardiac dysrhythmias;
 pulmonary Atelectasis;
 bronchospasm or bronchoconstriction;
 airway infection;
 bleeding or hemorrhage from the airway;
PREVENTION OF NOSOCOMIAL INFECTION

Definition
A nosocomial infection is specifically one that was not present or incubating prior to the
patient being admitted to the hospital, but occurred after 48 hours after admittance to the
hospital.

Types
 Blood stream infection
 Ventilator associated pneumonia
 Urinary tract infection
 Surgical site infection
 HAPU

Prevention of blood stream infection

 Strict hand washing
 Wear sterile gloves
 Aseptic techniques when inserting lines
 Optimal catheter site selection, with sub-clavian vein as the preferred site for
non-tunneled catheters
 Care of lines pre& post insertion
 Use & swabbing of clave connector
 Report early signs of infection
 Usage of transparent dressings
 To keep catheter flushed with heparin solution, if no medicine on flow
 Not to retain peripheral line for more than 72 hours and central line for more than 7
days
 To minimize add on devices
 Daily review of line necessity with prompt removal of unnecessary lines
 BLOOD GLUCOSE MONITORING

Blood glucose monitoring helps to evaluate effectiveness of medication, reflects glucose

excursion after meals, assess glucose response to exercise regimen and assists in the
evaluation of episodes of hypoglycemia and hyperglycemia to determine appropriate
treatment

Equipment
A tray containing
1. Blood glucose meter
2. Lancet/lancing device
3. Test strip
4. Disposable Gloves
5. Alcohol Wipe
6. Gauze piece
7. Cotton ball

Preprocedure preparation
 Identify the patient with two patient identifiers (Name and UHID Number) on
the patient’s ID Band
 Arrange all the equipment

Procedure
 Prepare the finger to be lanced by washing the patient hands in warm water and
soap. Dry thoroughly. (Washing in warm water will increase the blood flow to the
finger and remove superficial contaminants that could cause erroneous readings)
 An alcohol swab may be used to cleanse the finger .Alcohol must dry
thoroughly before finger is lanced.
 Don disposable gloves
  Turn on the glucose meter, and insert the glucose test strip.

 Before pricking squeeze the finger to ensure adequate blood supply, then prick

 The ideal site for prick is lateral side of 3rd or 4th finger of the non-dominant hand.
 Prick the patient’s finger using lancet/lancing device .Cover the test area
completely for accurate results.
 After pricking do not squeeze the finger because it may alter the blood glucose
levels
 Apply the blood carefully to the strip test area.

 Once the test is complete the lanced finger is covered with gauze or a tissue until
bleeding subsides. If necessary, an adhesive bandage is then applied.
 The articles used are to be replaced.

Documentation
The readings should be noted and reported to the concerned physician and the orders
should be followed.
CODE BLUE
Definition
It is a mode of alerting all medical, nursing paramedical and allied
healthcareservices personnel for cardiopulmonary resuscitation. Code blue denotes
“Cardiac Arrest of a patient requiring immediate resuscitation”

Guideline for code blue

In an event of sudden patient collapse BLS Support will be initiated by the trained
staff
members and simultaneously instruction will be given for a code blue team.

First announcement is made by dailing

 The announcement for code blue shall be repeated three times on the
over head communication system
 The Crash cart with all emergency equipment and drugs shall be moved
simultaneously to patient’s bedside.
 The emergency duty doctor/staff nurse shall bring with him the defibrillator.
 The code blue running sheet be filed with patients records
 The code blue quality review form shall be sent to MS office.

Trigger for code blue

 Trigger for code blue: Code blue is to be called in any case of cardio
respiratory arrest except
 Patients brought without cardiac activity in Emergency triage
 Operation theatres (unless help desired by Anesthetist)
 ICU unless help required by doctor on duty
 Code Blue can be activated by Any staff member

Code blue team members

 Team Leader- Internal Medicine Registrar
  Anesthesia Registrar
 Cardiac Registrar
 Resident Doctor of the Floor
 Nursing Supervisor
 Charge Nurse
 Allocated Staff Nurse
 Pharmacy supervisor of the floor
 House Keeping Supervisor of the floor
 For pediatric Code Blue, the pediatric registrar is the Team Leader and the
Pediatric resident is to be called.

Procedure
 The hospital has uniform use of resuscitation services throughout the
organization
 Announcement is made over the Public Address System for ‘Code blue’ at a
particular bedside. It is announced thrice and specifics adult/pediatric/neonate
 All code blue Team members are contacted on their cell phones indicating the
emergency requirement and the bed number.

Code blue response

 CPR to be started and continued by all available staff till arrival of code blue
team
 Bag mask ventilation to be done till arrival of anesthetist/on instructions of
Team Leader
 All staff to clear out on arrival of Code blue Team

Senior nurse
 Start recording events in the code blue running sheet
 Ensure availability of glucometer and BP apparatus through other nurses
 Create labels for blood samples
  Hand over the required medications to the Staff Nurse
 Dispatch blood samples to lab as required by the Team leader
 Process the patient for transfer to ICU/Mortuary at the end of Code blue

Priority for code nurse

 Obtain and open crash cart
 Hand over laryngoscope and ET tube to anesthetist/competent person
 Administer medications as per team leader
 Obtain blood sugar level by Glucometer
 Transfer the patient at the end of the code Blue

Priority for team leader

 Attach defibrillator leads and obtain baseline recording
 Interpret ECG finding and advise medications accordingly
 Ask nurse to do glucometer check
 Obtain ECG recording after every 5 minute interval or sooner if there is a
change in Cardiac rhythm
 Order DC shocks, medications, tests as required
 Confer with primary consultant at the end of the Code blue
 Patients family discussions at the end of the Code blue
 Write detailed CPR notes in the progress note at the end of the Code blue

Priority for anesthetist

 Establish airway and breathing
 Establish venous access if not done so far

Surgical registrar
 Establish vascular access and tracheotomy where necessary
Cardiac residents
 Start cardiac massage and rotate every 3 – 5 minutes
 Start venous access
 Give DC shock as advised by Team Leader
 Check vitals as desired by Team Leader

For Picu and Nicu

 Respective area clinical care coordinator
 Pediatric registrar
 Nursing Supervisor
 Charge Nurse/Team leader
 Housekeeping Supervisor and staff of the concerned area.

Airway assessment

Head Tilt-Chin Lift or Jaw Thrust

 Watch for the chest to rise and fall
 Listen for air exchange
 Feel air move through the mouth

If no breaths felt give (2) breaths assess circulation

 check carotid 10 seconds for adults
 check brachial for infants

If no pulse start compressions with ratio of (2) breaths to (30)

Compressions
“PLACE” monitor “LEADS” and “LEAN” monitor toward
physician. Attach Monitor Leads to Client
RA=right arm (white) RL=right leg (green)
 LA=left arm (black) LL=left leg (red)
Documentation
As per our Hospital
 It is the responsibility of the staff nurse to make sure code blue running
sheet and Resuscitation quality Management sheet is filled by the Medical
Registrar and sent to the DMS Office for performance review.

Replacement
The pharmacy supervisor of the floor has to replace the used crash
CARDIO PULMONARY RESUSCITATION

INTRODUCTION
CPR or cardiopulmonary resuscitation aims at bringing back the function of the heart
and lungs to normal as per the specific victim.

INDICATIONS
CPR is indicated for any person who is unresponsive with no breathing or only gasps
as breathing as it is most likely that they are in cardiac arrest

If a person still has a pulse, but is not breathing (respiratory arrest), artificial
respirations are more appropriate. However, many people often have difficulty
detecting a pulse and CPR may thus be use

PHASES AND STEPS OF CPR

Phases one; Basic life support
C. Circulation
A. Airway
B. Breathing
Phases Two; Advance life support (restoration and maintenance of effective
ventilation and circulation)
D. Drugs
E. Early defibrillation
Phases Three. Post resuscitative therapy

1. Check responsiveness
 Tap or gently shake the victim shoulders and shout Are you ok
 Do not force fully or vigorously shake the victim as spinal cord injur has not been
ruled out.
 If the victim is un responsive call for help
 The appropriate position for CPR is supine with arms alongside
 The rescuer should be at the victim side
Airway
Open the airway head tilt –chin lift maneuver; one hand on the forehead and afirk
Backward pressure is applied with the palm to tilt the head backward.
The index finger of the other hand is placed under the chin and lifted to bring the chin
Forward Jaw thrust maneuver; from behind the victims head, place each hand on
either side of the mouth rest the elbow. The thumbs are placed under the line of the
mandible. A forward displacement of the mandible is accomplished by grasping the
angle of the mandible and lifting with both hands.

Breathing
 Assess for efforts being made to breathe and whether ventilation is taking place
 Look for chest movement – rise and fall
 Listen for effort of breathing or breath sounds
 Feel for the exhaled breath on the cheek

If not breathing or breathing are not adequate give 2rescue breaths

Mouth to mouth; Keep the air way open .pinch the nose .seal the victim mouth
with the rescuers lips and use the exhaled air to ventilate the victim. Give two
slow breaths.

Circulation
 Assess for signs of circulation – carotid pulse (place the middle finger on the
Adams apple at the victims neck
 If no sign of circulation is present provide 15 chest compressions
 Locating the site of compression; place the middle finger at the lower rib cage
on the victim abdomen. Slide the fingers along the rib cage towards the thorax.
Locate the xiphoid process.
 Place two fingers of the hand above the xiphi sternum towards the head of the
victim.
 Place the heel of the other hand adjacent to the two fingers on the sternum.
  Place the palm of the second hand, over the heel of the first hand and interlock
the fingers.
 Keep the fingers of the first hand in extended position to prevent compression
of the chest wall.
 Performance of chest compression; do not remove the heel of the hand from
the site of compression, if removed, relocate the site again.
 Keep the hand parallel to each other.
 Lock the elbows keep the hands straight. The shoulders of the rescuer
should be directly over the hand the sternum should be depressed 1/2 to 2
inches Compression must be released to allow blood flow.

Ratio
 The ratio of rescue breaths and compression is 2; 30 .In a minute approximately
8-10resuce breath and 80-100 chest compression should be given
 Perform 4 cycles of rescue breaths and chest compressions and then re –
evaluate the victim’s status.

Aftercare
Emergency medical care is always necessary after CPR. once a person's
breathing and heartbeat have been is coming and talk positively until professionals
arrive restored, the rescuer should make the person comfortable and stay there
until emergency medical personnel arrive. The rescuer can continue to reassure the
person that help and take over.

Risks
CPR can cause injury to a person's ribs, liver, lungs, and heart. However, these risks
must be accepted if CPR is necessary to save the person's life.
Normal Results
 In many cases, successful CPR results in restoration of consciousness and
life. Barring other injuries, a revived person usually returns to normal functions
within a few hours of being revived.
 Abnormal results include injuries incurred during CPR and lack of success
with CPR.
 Possible sites for injuries include a person's ribs, liver, lungs, and heart.
Partially successful
 CPR may result in brain damage. Unsuccessful C P R results in death
IV CANNULATION

Definition:

Insertion of Cannula in to the vein for the primary purpose of administering medications/
Infusion therapy/ Transfusion of blood and its products.

Equipment:

Tray / Trolley containing.

 Gloves
 Alcohol Swabs.
 Safety cannula of appropriate size
 Clipper/ Scissors
 Tourniquet
 Syringe with needle
 Heparin Flush
 Clave connector
 Tegaderm
 Label
 Sheet protector
 Kidney Tray
 Vaccutainers (to collect samples if any)
 IV set – IV fluids/ blood as per advice if any
 Medications as per advice if any
 Patient record.
 Q- site
PROCEDURE

 Wash hands and keep the articles ready.

 Identify the patient using two identifiers (Name & UHID) IPNO.
 Check the indications for IV cannulation
 Explain the procedure to the patient
 Ensure that patient is in a comfortable condition
 Check the site and accessibility of the vein, (sites……) and patient’s preferences
if feasible.
 Ensure the cannulation site is free from hair ( clip hair in case of difficult
cannulation)
 Spread the sheet protector to avoid any soilage
 Apply the tourniquet around the patient’s arm above the intended cannulation
site.
 Ensure that tourniquet should be tight enough to impede venous circulation but
not too tight to obstruct arterial circulation.
 Ask the patient to close the hand firmly with arm well supported till the vein is
palpable.
 Rub hands with alcohol rub and wear gloves
 Ensure the site is cleaned with alcohol swabs.
 Insert the needle smoothly in to the skin at an angle of 30check the backflow of
the blood into the canula. If present, advance the canula into the vein carefully
without puncturing the vein through and through.
 Release the tourniquet and take out the needle keeping the cannula in site.
 Flush the cannula with Heparin flush and apply the needle less
connector(Heplock)
 Secure the cannula with tegaderm (transport dressing) and mark the date and
time of the cannulation.
 Administer medication/ IV fluid/ Blood if any – as per prescription.
  Flush IV cannula with heplock
 Ensure patient is kept in comfortable position post the procedure.
 Check the comfort of the arm.
 Replace the articles and dispose the waste as per policy
 Remove gloves and wash hands
 Document the procedure and patients response in the Nurses notes.
 Check on the patients comfort.
 Look for signs of inflammation/ extravastions if the cannula has to be left in situ.
 Change cannula if discomfort or pain persists.
 Follow hospital policy for TAT(Turn Around Time for removal)
 Discard waste as per policy
 Clean and replace the articles.

Points to remember

 Do not puncture the arm with an AV fistula/ shunt/Lymph Oedema/Burns/ Surgery

etc.
 Do not apply tourniquet too tightly and remove within- minutes
 Do not forget to remove the torniquet.
 Use safety cannula to avoid Needle stick injuries.
 Use needleless connectors instead of ports.
 Keep the cannula patient using Heparin flush(Heplock)
 Do Not re- puncture using same needle in case of an difficult access.
 For pre – operative patients cannulate on the left arm unless difficult/
contraindicated.
 Check for patency during intermittent infusion/ medications.
 Remove if any redness/ swelling/ discomfort is / reported.
 Remove cannula before discharge of the patient.
  If IV access is not possible with single puncture, then seek help from
doctor/Anesthetist.

SPUTUM COLLECTION

Purpose:

To obtain an uncontaminated sputum specimen for culture, smears, malignant

cells etc.
For a diagnostic purpose and for treatment.
To determine antibiotic sensitivity.

Equipment:

A clean tray containing:

 Waterproof disposable sputum cups with wide mouth.

 Sterile cotton applicator.
 A glass of water
 Sterile specimen container.
 Microbiology request form and the clinical data form.
 Disposable gloves
 Tissue wipes.

Procedure:

 Wash and dry hands.

 Identify the patient by checking the identification bracelet and ask the
patient his or her name.
 Explain the procedure to the patient.
 Place the tray on the over bed table near the bed side.
 Container should be given on the previous night after proper explanation.
  Instruct the patient to raise the material from the lungs by coughing and
not simply the saliva or discharges from the nose or throat.
 The sputum should be collected in the morning before brushing the teeth
or taking food.
 Mouth can be rinsed with plain water and not with any antiseptic mouth
washes.
 Tell the patient to collect sputum in the sterile container. It should not be
spilt outside the container.
 After collecting the sputum, container should be closed.
 Instruct the patient to wash the mouth and hands after collecting sputum.
 Ensure that specimen and microbiology form is clearly and correctly
labeled.
 Send the specimens to the laboratory.
 Remove, clean and replace the articles as appropriately.
 Dispose the disposable items
 Wash and dry the hands.
 Document the procedure in the patient’s file.

Collection of sputum from children.

Explain the procedure to the parents.

Gain confidence of the child by the help of parents.
Use a cotton applicator and a test tube.
When the sputum is coughed up, wipe off the sputum with cotton applicator and
dropped in to the clean test tube with a cotton plug.

NB: Aseptic precautions to be taken while a sample is collected for culture.

CARE OF DYING PATIENTS
PURPOSE:

To provide standardize care to dying patients.

Care of dying patients

 The nurse shall understand the grief process and the meaning of loss/death
to the family.
 The nurse shall assess both the patient and family’s emotional state and
coping mechanism and wishes for end of life care.
 The nurse shall communicate what is known about client preference and
decisions in change of shift report, written care plans and ongoing
consultation with physicians and other team members.
 The nurse shall use open ended questions, attentive listening, and presence
to allow clients to freely share their thoughts and concerns.
 The nurse shall provide relief from pain as ordered.
 The nurse shall provide thorough personal hygiene including skin care,
mouth care, eye care, back care etc.
 Frequent rest periods will be provided to conserve energy and prevent
fatigue.
 Small and bland food with low residue which is palatable shall be provided.
 Medications and oxygen shall be administered as ordered.
 Religious needs shall be met as per the patient and family’s desire and
hospital policy.
CARE OF COMOTOSE PATIENTS

Purpose:

To provide standardize care to unconscious/ comatose patients.

All unconscious/ comatose patients should be monitored for the following hourly:

 Vital signs
 Neurological status using Glasgow coma scale
 Intake and output.
 Pain
 Ventilator parameters if applicable.
 Spo2 if applicable
 CVP if applicable
 PA/PAWP if applicable.
 Cardiac output if applicable.

Procedure:

 If ventilated and unconscious patients should be given back care and positioning
every 2nd hourly.
 Mouth care should be given to all ventilated patient’s 4th hourly.
 Daily sponging shall be done.
 ABG should be done on a daily basis or as applicable.
 ET tube should be checked after each suctioning and positioning of the patient
for patients with ET tube.
 Catheter care should be given 4th hourly.
 Eye care should be done 4th hourly. Vigil shall be kept for any infection.
 Eyes are closed using tegaderm to prevent dryness of cornea.
 Patients should be suctioned with single use disposable catheters and separate
for E/T tracheostomy and oral.
 Suctioning should be done before feed or as applicable.
 All flushing solutions used for suctioning should be single use and disposed off
after each suctioning.
 Flow sensors of the humidifiers are changed for each patient and sterilized by
ETO.
 Steri cath should be changed every 48- 72 hours.
 All central lines and arterial line should be covered with sterile sheets changed
every day or visibly soiled.
 All ventilator tubbings and C circuit should be changed every 7th day or if it is
required earlier.
 Fluid and nutrition shall be maintained with IV fluids and or enteral feeding.
 The position of ryles tube should be checked before giving each feed.
 Keep head and elevated at 30* unless contraindicated.
 Anti – embolism stockings are applied or anticoagulants are started to prevent
DVT.Limbs are supported in a position of anatomical function.
 Range of Motion exercise are performed as advised by the physician.
 Special mattress should be used to relieve pressure if applicable and pressure
points shall be inspected for any redness.
 Tracheostomy care should be given shift for patients with tracheostomy.
 If required tracheostomy tube is changed by the doctor.
 Tracheostomy tape should be changed by the doctor whenever required.
 Extra tracheostomy tube of the same size should be kept with the
patient.Patient’s clothing and bed linen is changed daily or whenever needed.
 T prevent constipation adequate fluid will be administered.
End of life issues:

 Family should be assessed for psychological, spiritual and bereavement

support.
 Document should be done at least once.
 Medical social worker should be informed.
 End of life form should be filled.
 Religious needs should be met (List of religious service providers available.)
 Organ donation is encouraged if applicable.
CARE OF VALUABLES
Purpose:

To prevent the loss of patients belongings during hospital stay.

 Hospital is not responsible for patient valuables/ property that is not deposited
with hospital security for safe keeping.
 Nurses shall encourage the patient family on admission to take identified
valuables and patient property home.
 If it is not feasible the patient family shall be informed of the patient valuable
policy and encouraged to store valuables in hospital security safe deposit boxes.
 The nurse should call the security and handover the valuables which are not
taken home.
 Entry is made as white metal/ yellow metal and signature obtained and retained
with security and with a copy in the life.
 If there is no attendant then the security takes charge of the items.
 The master key of the safety lockers are with CSO and patient on discharge can
produce the receipt and receive the items after thorough verification.
 In case of loss of any valuable the complaint is lodged with CSO.
CARDIAC CATHERTERISATION

PURPOSE:

To outline the management before, during and immediately following cardiac

catheterization.

SCOPE:

Cath Lab.

 Identify the patient using two identifiers.

 Check the order for the procedure.
 The doctor explains the procedure to the patient.
 Blood sample is drawn for the following investigation under strict asepsis.
o Urea
o Creatinine
o Electrolytes
o RBS
o CBC
o PTT
o BT
o CT
o HbsAg
o HIV I & II
o Blood grouping.

 ECG, X ray chest to be done

 Skin preparation is done as per the order.
 Ensure the consent is taken for the procedure.
 NBM as advised
 Patient to be sent to cath lab with a front open gown
 Wait for the call from the cath lab
 Shift the patient wit hall reports and file.
TRANSFER OUT FROM WARD TO WARD/ WARD TO ICU/ ICU TO WARD/ TO
DIAGNOSTICS TO / OPERATING ROOM.

PURPOSE:

To provide guidelines for transfer of patients.

SCOPE:

Hospital wide.

 Transfer the patient from one unit to another only after a written order from the
doctor.
 Explain to the patient and relatives about the transfer.
 Check and document the vitals before transferring the patient to ward/ICU/
Diagnostics/ Operating Room.
 Check the ID band before transferring the patient to ward/ICU/ Diagnostics/
Operating Room.
 Inform ward secretary regarding transfer out and any special requirements like
oxygen, special bed, suction, etc.
 Inform ward secretary to confirm the availability of bed through admission
counter and concern floor secretary.
 Floor charge nurse to contact the concerned unit charge nurse and confirm about
the bed availability and briefs on patients condition and any special things to be
arranged. After 5.30pm to 8 am next morning, on duty Nursing supervisor to do
the needful.
 Return unused consumables/medicines to pharmacy
 Receive all the indents which are made for the patient.
 Diet change/ transfer to be done in the computer by the ward secretary.
 Ensure in house transfer form is filled
 Confirm the status of readness of the bed in the receiving unit before shifting.
 Arrange stretcher/ wheel chair according to the patient’s condition.
 Shift the patient to the concerned unit along with the attendants.
 Document the number of reports, X rays, CT scan/ MRI etc. behind the clinical
chart and get a receiving signature from the receiving nurse.
 The assigned nurse accompanies the patient with the patient’s case file, all
investigation reports available, patient’s medicines and consumables and hands
over the assigned staff nurse of the receiving unit.
 Ensure computer entry of transfer out is done.
 The nurse who receives the patient orients the patient and attendant to all the
facilities.
 All orders stand cancelled when a patient is shifted from ward to ICU/ HDU or
vice versa and fresh orders to be written.
 CAPS reassessment to be done when a patient is shifted from ICU/ HDU to ward
and when these is a change of status.
 After receiving from Ward/ICU/ Operating Room/Diagnostics, nurse has to check
the following:
 Document and reports
 Patient condition and vital signs
 Assessment for any skin peeling / bedsore.
 IV line, drain & dressing if any
 Medications, thermometer and any other equipment which the patient
uses.

 The receiving nurse documents all the above and documents the receiving time
in the shifting notes.
TRANSFERING THE PATIENT FROM WARD TO O T.

 Check the OT list for schedule and coordinate with the OT for transfer.
 Identify the patient using two identifiers.
 Check for
- Name of the patient and the Surgery to be performed.
- Pre operative investigations/ medications if any.
- Consent for Surgery.
- Arrangement of Blood and its components.
- Physician Clearance.
- Cardiac clearance and high risk consent if necessary.
- P.A.C.
- NBM as ordered.
- Site marking
- Skin preparation as ordered.

 Check for all the reports, old file of the patient and document the same behind
the Pre operative checklist.
 Ensure sponge/ a bath is given for the patient before shifting to OT.
 Provide gown for the patient.
 Administer pre medications if any, check the vital signs and document just before
shifting.
 Ensure the pre operative checklist is completed.
 Check the request slip from the OT before shifting.
 Explain about the shifting to the patient and the attendants.
 Shift the patient to OT with all the reports and file.
 Handover the patient and reports to the pre operative nurse.
 Request attendants to wait in the waiting lobby.
 In case of an ICU bed booking for post operative period hand over all patient
belongings to attendants and explain about the transfer.