ASSESSMENT Physically remove cigarettes from the room (put it on the assessor’s table,
assuming that it is the ward cupboard).
1. S AFETY
First, I will assess that the scene is safe, there are no wires or water spillages
that may cause any trips or slips.
2. P RIVACY
Next, I will draw the curtain close to ensure my patient’s privacy and dignity.
3. H ANDWASHING
Now, I will perform hand washing according to the World Health Organization
Guidelines.
a. Open the tap and wet my hands.
b. Apply soap.
c. Rub palm to palm.
d. Palm over dorsum with interlaced fingers.
e. Palm to palm with fingers interlaced.
f. Fingers interlocked.
g. Thumbs.
h. Fingertips.
i. Wrists.
j. Rinse.
k. Close the tap using my elbows.
l. Dry my hands thoroughly, using paper towels, from fingertips to wrists.
m. Dispose the towel into the black bin or according to Trust Policy.
4. E QUIPMENT CHECK
Then, I will check that my equipment are clean, well-calibrated, and within the
service date.
5. G REET / GAIN CONSENT
I am now ready to approach my patient. “Hello, Mr/Ms/Mrs (name), my name is
(your name), I am the nurse looking after you today. How would you like me to
call you? Alright (name), I have been asked to do your assessment which will
take around 15 minutes and includes taking a set of observations and asking
some important questions that will help in the development of your care plan, is
that alright with you?”
6. I DENTITY
Check against assessment form. “May I check your wrist band? Can you tell me
your full name? And date of birth please? And your MRN number is ######
(MRN ######). Thank you.” I have confirmed that I am with the right patient.
7. A LLERGIES
“I can see that you have a red wrist tag on, what are you allergic to? What is your
reaction when you take (allergen)?”
8. L ATEX ALLERGY
“Do you have a reaction to latex or rubber products? (If yes) What kind of
reaction do you have?”
“I will make sure to document your allergy to (drug/latex), so rest assured that
during your stay here in the hospital, you will not receive any (drug/drug-based/
latex or rubber products).”
“Do you have any concerns before we start?” Address patient’s concerns
immediately, such as, breathlessness (elevate head of bed, reposition, pillows),
pain (proceed to pain assessment), questions about procedure if pre-op (refer to
doctor), independents or pets (ring their contact person/social worker after the
encounter), etc.
“Are you happy for me to continue with the assessment?”
9. B EDSIDE TRAPS
a. Glasses/Hearing Aids
“I can see that you have (glasses/hearing aids), are they yours? Would you like
to use it during the assessment?
(If yes) Let me help you in putting this on. Can you see/hear me better now?”
(If no) Alright, when do you use it? Ok, I will take note of that.”
b. Cigarettes Sticks/Lighters
“I can see that you have (cigarettes/lighters) in here, are they yours?”
YES - “How long have you been smoking? Do you have any plans to quit?
(If yes) I can provide you leaflets regarding quitting smoking after our little chat
and when you are ready, I will be a happy to make a referral to the Smoking
Cessation Team for you.”
(If no) Can I offer you some nicotine patch or gum to help you instead?”
NO - “Do you know whose these are?”
“(Name), as this hospital is a non-smoking facility and we are surrounded by
(piped-in oxygen/oxygen tanks) and other equipment which are highly
combustible and may start fire in the presence of smoke, I am afraid I have to
take these away and keep it locked in a safe place or give it to your relatives to
take away when they come to visit.”
c. Sweets/Glass of Water
“I can see that you have (sweets/a glass of water) in here, has anyone advised
you on your diet status, if you are nil by mouth?
(If no) Ok, after this assessment, I will check your diet status on the chart and
inform you of this as soon as I can, alright? In the meantime, may I ask you not
to eat or drink yet until I get that information, ok?”
(If pre-op) As a part of your pre-operative preparation, you are advised not to eat
or drink for a certain number of hours so that your risk for aspiration during the
procedure will be greatly reduced. Let me just check on your chart when this
should commence and I will inform you of this as soon as I can after this
assessment.”
d. Specimen Cup/Sputum Pot
“I can see that you have a specimen cup in here, do you know what to do with it?
(If no) Ok, I will check on your chart if you need to collect any specimen and get
back to you after this assessment.”
(If sputum pot) Are you able to expectorate? We may need to collect a sputum
sample for analysis so please let me know if already have the sample so I can
send it to pathology. I can assist you in doing deep-breathing and coughing
exercises after this assessment. If it is alright with you, I can also refer you to the
chest physiotherapist to aid in the mobilisation of your secretions.”
e. Mobility Devices
“Is this (mobility device) yours? How long have you been using it? Are you steady
on you feet? I can make a referral for you to the physiotherapist to assist you in
using your device, would you like me to do that? On which side would you like
me to place you mobility device?”
f. Inhalers
“Is this inhaler yours? When do you use it? How long have you been using it?
Are you confident in its use? Do you have any concerns regarding your inhaler?”
In the case that a peak flow measurement needs to be obtained, I should make
sure that the patient is rested before doing the procedure, and both pre- and
post- medication measurements are recorded.
“Do you have any concerns before we proceed to the observations?”
10. O BSERVATIONS
“Now, we will proceed to taking a set of observations, which includes your blood
pressure, oxygen saturation, temperature, pulse rate, and respiratory rate. Is it
alright for me to continue? Let me just put your details here in the NEWS Chart.”
Since I have already checked earlier that my equipment are ready for use, I can
proceed with taking observations. I will then do my hand rub before I start using
the same technique for hand washing.
a. Blood Pressure
Before taking the blood pressure, I will make sure that the patient had at least a
5-minute period of rest and that their legs are not crossed. Also check for
oedema and IV lines in situ.
“May I ask if you have any previous surgeries, traumas, or AV fistulas on either
arm? Any medical condition that will restrict us from using this arm?”
I will then place the cuff on the patient’s arm, ensuring that it is the appropriate
size and it covers 80% of the arm circumference, positioned 2-3 cms above the
antecubital fossa, and aligned with the brachial artery.
“So (name), while the blood pressure is being taken, you will experience
tightening on your arm which is expected.”
b. Oxygen Saturation
“Now, I will clip this pulse oximeter on the finger of the other hand to measure the
oxygen saturation of your blood.”
We check that the finger we use is clean, free of lesions or scars, and not
showing any signs of cyanosis.
c. Temperature
“I will now take your temperature using this tympanic thermometer.”
I will inspect the ear canal for the presence of wax, drainage, blood, or foreign
bodies. If the patient has hearing aid on, it should be removed from the ear 10
minutes before taking a reading. Then place a disposable probe cover on the tip,
place the thermometer in the ear aligning the probe tip with the ear canal and
gently advancing until the probe seals the opening ensuring a snug fit. After
using the thermometer, dispose the probe cover into the domestic waste bin or
according to Trust Policy.
Remove devices. Document the findings on the NEWS chart, stating the
measurement, whether it is within normal limits, and the score corresponding to
each measurement. If patient is on oxygen therapy, record FiO2 instead of L/min.
Hand rub.
d. Pulse Rate and Respiration Rate
“Ok then (name), may I ask you to keep still and stay silent for 2 minutes while I
take your pulse rate?”
Page 1 of 18
 I will place two fingers along the artery and apply a gentle pressure until a pulse
is felt, counting the number of beats and noting the rate and rhythm as well. After
taking the pulse rate for a full minute, I will then take the patient’s respiratory rate
without informing them. This ensures that they will not alter their breathing
pattern. I will also take note of any increased work of breathing or use of
accessory muscles. Do full minute RR.
Document the findings on the NEWS chart, stating the measurement and the
score corresponding to each measurement.
e. AVPU
Proceeding to the AVPU scale, I can see that the patient is fully awake, has
spontaneous opening of the eyes and motor function so I am happy to put an ‘A’
for ‘Alert.’
Calculate the total NEW score. If necessary, do neuro obs first before calculating
total NEW score. “Your total NEW Score is (score) which means that we will
monitor your observations every (number of hours).”
0 (minimum 12 hourly), 1-4 (4-6 hourly), 5 or more or 3 in one parameter (every
hour), 7 or more (continuous).
f. Pain Scale
“Are you in any pain?”
YES (PQRST) - “Where is it located and does it radiate? Do you know what
causes it? When did it begin and what circumstances are associated with it?
How will you describe it? How will you rate your pain from 0-10, with 0 being no
pain to 10 being the worst pain ever? What makes the pain worse? What helps
to relieve it?”
Pain medications - “Have you been given any analgesia for your pain? When
was it last given? Did it help?”
NO (and the time the medication was given has not yet passed 30 minutes to an
hour, which is the time oral meds kick in) - “Ok, let us wait for some more time to
allow the medication to fully take effect and re-assess after.”
NO (and you are unsure when the last dose is given or the patient requests for
another pain med) - “I will need to verify on your medication chart the time the
medication was last given.” OR “ I will need to look on your medication chart to
make sure you are up-to-date with the medications to keep your pain under
control.”
g. Miscellaneous
BLOOD SUGAR - “Do you know if you are diabetic? Do you take any
medications for it? Has your blood sugar been taken? I will check on your chart if
you need blood sugar monitoring and get back to you as soon as I can after this
assessment.” In the meantime, I will put NA on the chart for not assessed.
(If patient is worried about their blood sugar level) “Please be assured that your
blood sugar will be monitored accordingly; however, if you experience any signs
of low blood sugar, such as rapid heartbeat, sweating and clamminess, hunger,
nausea, shakiness, or lightheadedness, please let us know immediately by
pressing the orange button on the call bell.”
Target blood sugar - 5.0-9.0 mmol/L. Signs of hyperglycaemia include increased
thirst, headache, trouble concentrating, blurred vision, frequency in urination, and
fatigue.
URINE - “Have you passed urine since you woke up?” (If yes) I will put PU on the
chart for ‘Passed Urine.’ (If no) I will put NPU on the chart for ‘Not Passed Urine.’
“As a part of the admission process, you will have to provide a urine sample for
routine urinalysis using the clean-catch, midstream technique for urine specimen
collection. I will bring you a bedpan/bottle after this assessment.”
After taking the observations, I will check the NEWS Chart for completeness,
including date and time, and affix my initials.
ESCALATION PLAN - Y
11. N EURO OBS
I will now perform neurological observations.
a. Eye Opening
By observing the patient as I approached him/her earlier on, I have already
assessed (he/she) has spontaneous eye opening, so I am happy to give him a
score of 4 (spontaneously).
3 - to speech, 2 - to pain, 1 - no response.
b. Best Verbal Response
For best verbal response, the patient was able to state (his/her) full name
correctly, which is an indication of orientation to person. “So (name), do you
know what is today’s date? And where are we now?” (If patient answers
correctly) The patient has given the correct answer for each question so I am
happy to give (him/her) a score of 5 for orientated.
4 - confused, 3 - inappropriate words, 2 - incomprehensible sounds, 1 - no
response. If the patient is becoming disorientated, changes will occur in this
order: time - place - person.
c. Best Motor Response
We then assess the patient’s best motor response by using two-step commands.
“Can you grasp my hand and release it?” OR “Can you open your mouth and
stick out your tongue?” The patient obeys command therefore I will give (him/her)
a score of 6.
5 - localises pain, 4 - withdraws (normal flexion), 3 - abnormal flexion (decorticate
posturing), 2 - extension to pain (decerebrate posturing), 1 - no response.
The patient’s Coma Scale score is (score) which is an equivalent of (NEW Score)
in the NEWS Chart.
d. Pupils
Now we assess pupillary size and reaction to light. “Can you open your eyes
please?” Normal pupils are round and equal in size with a diameter ranging from
2 to 5 mm.
“Can you hold the (left/right) eyelid open?” Then we shine a bright light into the
eye, moving from the outer corner of the eye towards the pupil. This should
cause the pupil to constrict immediately and cause an immediate and brisk
dilation of the pupil once the light is withdrawn. Do the same with the other eye.
“Can you hold both eyelids open this time?” Now we shine the light into one eye
only. Both pupils should constrict immediately and briskly dilate once the light is
withdrawn.
I will now record on the chart the pupillary size in millimetres and reactions on the
chart using a positive sign (+) for brisk reaction, or a negative sign (-) for no
reaction.
e. Limb Movement
Then we proceed to assess limb movement. “Can you close your eyes and hold
your arms straight out in front with palm outwards?” We observe for 20-30
seconds for any sign of weakness or drift. OR do hand rub first then, “Can you
hold your arms straight out in front of you then flex them against my resistance?
Do you feel any weakness?”
If the patient can maintain this position, record the power as normal. If an arm
drifts downwards or the patient cannot maintain this position, record the relevant
limb as mildly weak. If the patient is unable to lift their arms but can make some
movement (e.g. move fingers), record as severely weak.
Now for leg strength. “Can you raise your leg off the bed?” OR do hand rub first
then, “Can you raise your legs off the bed against my resistance? Do you feel
any weakness?”
Record whether the power of each leg is normal or mildly weak if observed. If the
patient cannot lift their legs off the bed but can make some movement (e.g. move
toes), record as severely weak.
We can also test flexion and extension strength in the patient’s extremities by
having the patient push and pull against resistance.
12. A CTIVITIES OF DAILY LIVING (ADL’S)
“Ok then, are you still happy for me to continue with the assessment? I will be
asking you some pertinent questions and will take a few more minutes. Is that
alright?” Position yourself at patient’s eye level. “Are you comfortable for me to sit
down and write down notes while we do the assessment? May I just ask what
brought you to the hospital?”
a. Maintaining a Safe Environment
i. “Do you know today’s date? And where are we now?”
ii. “Have you had any falls before?”
iii. “What was the reason? Did you acquire any injuries?” (If yes) I will make sure
to complete a Trust Falls Care Plan after this assessment.
b. Communication/Pain
i. We have already established earlier in the assessment the patient’s need for
glasses/hearing aids as well as their pain level.
ii. The patient can also speak and understand English without the need for
translation.
ii. “Have you had any previous eye or ear infection, surgery, or procedure?”
c. Breathing
i. We have already discussed the patient’s history of smoking and plans of
quitting earlier as well.
ii. “Do you experience any difficulty of breathing? What causes and relieves it?”
iii. “Do you have any history of chest infection or other respiratory problems? (If
asthmatic) What are the factors that trigger your asthma?”
iv. (For productive cough) “Are you able to expectorate? Have you tried doing
deep-breathing and coughing exercises? I can assist you in with doing these
exercises after this assessment and then we may need to collect a sputum
sample for analysis. I can also refer you to the chest physiotherapist to aid in the
mobilisation of your secretions.”
d. Eating and Drinking
i. “Do you experience difficulty in swallowing? Are you experiencing nausea or
vomiting? (If with dysphagia) Ok, I can refer you to the Speech and Language
Therapist to help you with your concern, would you like me to do that?”
ii. “Do you have any missing or loose tooth? Do you wear any dentures and do
they fit you well?”
iii. “Do you require a special diet? (If yes) Alright, I can refer to you the dietician
and inform the kitchen of your special diet.”
Page 2 of 18
 iv. “Have you lost or gained weight recently?”
v. “Do you drink alcohol? How often and how much?”
vi. (If pre-op) “When was the last time you ate or had a drink? Ok, I will check
your plan of care regarding your diet.”
e. Elimination
i. “Do you have any concerns regarding passing urine?”
ii. “How often do you need to urinate (frequency)?”
iii. “How immediate is the need to urinate (urgency)? Are you continent? Are you
able to maintain control over your bladder?”
iv. “Do you wake up at night to urinate (nocturia)? (If yes) Ok, I will provide you
with a bedside commode and non-slip socks so you don’t have to walk to the
toilet at night.”
v. (If with catheter) “What was the indication for the placement of the catheter?
When was it put on? When was it last changed? Who does catheter care?”
vi. “How often do you normally have your bowels open?”
vii. “Have you noticed any change in your bowel habits? (If yes) Alright, I will let
your doctor know and then we may need to collect a sample for analysis, ok?”
f. Personal Cleansing and Dressing
i. “Do you usually wash and dress yourself?”
ii. “Would you prefer a male or a female nurse to assist you with personal
hygiene if required?”
13. REMEMBER
If patient asks what National Early Warning Score (NEWS) is - “It is a
physiological scoring system used to document observations that helps nursing
and medical staff recognise any medical deterioration and triggers a timely
clinical response. Your score also determine how frequent your observations will
be monitored.”
If running out of time - “Do you have any concerns regarding your care?” OR “Is
there anything that bothers you?”
If patient verbalizes anxiety - “What makes you feel that way?”
If patient asks regarding consent for procedure - “Alright, I will speak to the
doctor after this assessment so that he may explain and answer your queries
about the procedure and gain your consent.”
Gain consent for all referrals.
Smile and make appropriate eye contact.
Never forget side rails and call bell.
Obs normal values (adults)

g. Controlling Body Temperature Pulse Rate: 60-100 bpm

i. “Are you feeling too warm or cold in this room? Do you need additional Respiratory Rate: 12-18 cpm
blankets?” Temperature: 36-37.5 0C
ii. (If hyperthermic) “Have you taken any antipyretics? I will need to verify from Blood Pressure: 110-140 mmHg systolic / 70-80 mmHg diastolic at rest
the medication administration record if and when the medication has been Oxygen Saturation: 95-100%, 88-92% in patients with respiratory
given.” problems
iii. “Have you been shivering or sweating excessively?”
Oxygen flow rates for nasal cannulas
h. Mobilisation
i. “Are you able to move around independently? Are you able to move up and 1 L/min - 24%
down, roll and turn in bed?” 2 L/min - 28%
ii. “Do you use any mobility devices (cane, frame, walker, tripod, etc.)? How long 3 L/min - 32%
have you been using it? On which side would you like your mobility device to 4 L/min - 36%
be?” 5 L/min - 40%
iii. “Are you steady on you feet? Do you experience shaking or unsteady gait 6 L/min - 44%
while walking?”
iv. “Do you experience difficulty initiating a walk or stopping?” Approximate oxygen concentration related to ow rates of semi-rigid masks

i. Working and Playing 2 L/min - 24%

i. “How do you spend your days? Do you work?” 4 L/min - 35%
ii. “What do you like doing in your spare time?” 6 L/min - 50%
iii. “Has your condition affect your work or hobbies?” 8 L/min - 55%
iv. “Would you like to ring your family to bring some of your belongings?” 10 L/min - 60%
12 L/min - 65%
j. Expressing Sexuality 15 L/min - 70%
i. “Do you live alone or with someone?”
ii. “Are you currently in a relationship? How long have you been married? Do you
have children?”
iii. “Do you have any concerns regarding your body image?”
iv. “Has your condition had an impact on the way you and your partner feel about
each other?”

k. Sleeping and Rest

i. “What is your usual sleeping pattern?”
ii. “How many pillows do you need to sleep?”
iii. “Do you experience difficulty of breathing when asleep or lying down?”
iv. “Do you have any bedtime routine or do you require night sedation?”
v. “Do you experience any sleep disturbances?”
vi. “Do you tire easily?”

l. Death and Dying

i. “Do you follow any religion?”
ii. “Would you like see or speak to someone in particular?”
iii. “Has your present condition affect your view about the future?”

12. 5 AFTER’S
“Alright (name), I think we have covered most of the things we need to make an
effective care plan for you. Thank you very much for your active participation. Do
you have any more questions or concerns?”

“Here is the call bell. Use it if you need any assistance by pressing this button. If
you do so, we will hear a sound we will be with you as soon as we can.”

“Are you comfortable?” (If no) “Let me assist you to a more comfortable position.
Is that better? Would you like your side rails to be raised? Is there anything else I
can help you with?” We then ensure that the bed is in its lowest level and
everything the patient needs including his assistive devices are accessible and
within reach.

Then I will do infection control including hand washing and cleaning the
equipment, complete documentation accurately and escalate any problem
encountered accordingly.

Page 3 of 18
 IMPLEMENTATION
1. S AFETY
First, I will assess that the scene is safe, there are no wires or water spillages
that may cause any trips or slips.
2. P RIVACY
Next, I will draw the curtain close to ensure my patient’s privacy and dignity.
3. H ANDWASHING
Now, I will perform hand washing according to the World Health Organization
Guidelines.
a. Open the tap and wet my hands.
b. Apply soap.
c. Rub palm to palm.
d. Palm over dorsum with interlaced fingers.
e. Palm to palm with fingers interlaced.
f. Fingers interlocked.
g. Thumbs.
h. Fingertips.
i. Wrists.
j. Rinse.
k. Close the tap using my elbows.
l. Dry my hands thoroughly, using paper towels, from fingertips to wrists.
m. Dispose the towel into the black bin or according to Trust Policy.
4. E QUIPMENT CHECK
Then, I will check that the drug trolley is clean and securely locked; however, for
the purpose of this OSCE, it is already opened.
5. G REET / GAIN CONSENT
I am now ready to approach my patient. “Hello, Mr/Ms/Mrs (name), my name is
(your name), I am the nurse looking after you today. How would you like me to
call you? Alright (name), at this time I will be doing my (time) drug rounds. Are
you happy for me to continue?”
6. I DENTITY
“May I check your wrist band? Can you tell me your full name? And date of birth
please? Alright, and your MRN number is ######. Thank you.” I then check that
this drug chart is attached together and belongs to the same patient whose full
name is (name), date of birth (dd/mm/yyyy), and MRN number ######.
Succeeding pages also contain the same details. I am happy to confirm that I am
with the right patient and I have the right drug chart.
7. A LLERGIES
“I can see that you have a red wrist tag on, what are you allergic to? What is your
reaction when you take (allergen)?”
8. L ATEX ALLERGY
“Do you have a reaction to latex or rubber products? (If yes) What kind of
reaction do you have?”
“Alright, I will make sure that your allergy to (drug[s]) (is/are) properly noted on
this medication chart and all other relevant documents; rest assured that during
your stay here in the hospital, you will not receive any (drug/drug-based/latex or
rubber products).”
9. DRUG ADMINISTRATION
Proceed to the drug trolley. Read the entire drug chart to the assessor. Prepare
drugs in separate pots if you are going to give it.
10. REMEMBER
Once you are ready, do hand rub and approach the patient. Check identity,
allergies, latex allergy again.
So now I will read through the drug chart. For every drug that I will give, I will
adhere to the 5 rights of medication administration: right PATIENT, right DRUG,
right DOSE, right ROUTE, and right DATE AND TIME of administration. I will also
check that any medication that is due does not provide an allergy for the patient.
On to the first page of the drug chart, the patient has known allergy to (drug), the
type of reaction is (reaction), signed by Dr (name), and dated today. In the
information for prescribers, (read information for prescribers). As for the
information for nurses administering medications, I should record the time, date
and sign when medication is administered, or use appropriate codes if a
medication is not administered.
Does the patient have any documented allergies? Yes, to (drug). Ward is (ward),
consultant is (name). Does the patient have any special dietary requirements?
Yes, specifically (special diet). Height, weight, and BMI should also be
documented to ensure accuracy with medication dosage calculation. BMI also
helpful in determining positive or negative fluid balance especially if patient is on
IV fluids.
The first page is complete; I am happy to proceed to the next page which still
belongs to (name). Does the patient have any documented allergies? Yes, to
(drug).
Proceed to ONCE ONLY AND STAT DOSES. The first drug is (drug, dose, route),
prescribed today at (time due) by (prescriber’s name) with bleep number ###,
given by my colleague (RN name) at (time given). Same with each succeeding
drug.
Proceed to PRESCRIBED OXYGEN THERAPY. For prescribed oxygen therapy,
prescribed today at (time due) by (prescriber’s name) with bleep number ###, to
target oxygen saturations (level), (therapy instructions), using (device) with flow
of (flow). What is the oxygen saturation and respiratory rate of the patient? If the
patient is meeting the desired oxygen saturation without oxygen therapy, I will
then continue to monitor the oxygen levels along with the complete set of
observations. But for now, I will not administer oxygen. However, if the patient is
obtaining and maintaining target saturations on oxygen therapy, I would liaise
with the medical staff to consider weaning the patient off the oxygen therapy.
Proceed to PRN (AS REQUIRED MEDICATIONS). For PRN medications, ask
the patient’s condition and do assessment prior to giving the medication. If no
drug is indicated at this particular time, I should still check the completeness of
the prescription and when it was last given, including checking against STAT
doses and regular medications.
On to the next page, still the drug chart belongs to (name), with documented
allergy to (drug).
Proceed to ANTIMICROBIALS. The first drug is (drug), prescribed today, (dose,
frequency, route, duration). Start day is (today/tomorrow) and the finish date is in
(duration). Prescribed by (prescriber’s name) with bleep number ###. Check that
patient is not allergic to the drug, if it is due your time, when it was last given,
code for non administration, signature of nurse administering medication.
On to the next page, still the drug chart belongs to (name), with documented
allergy to (drug).
Proceed to REGULAR MEDICATIONS. The first drug is (drug), prescribed today,
(dose, frequency, route, duration). Start day is (today/tomorrow) and the finish
date is in (duration). Prescribed by (prescriber’s name) with bleep number ###. I
also have to verify that due medications are not previously given as PRN
medication or STAT dose. Check that patient is not allergic to the drug, if it is due
your time, when it was last given, code for non administration, signature of nurse
administering medication.
On to the next page, still the drug chart belongs to (name), with documented
allergy to (drug).
Proceed to INTRAVENOUS FLUID THERAPY. On to the last page, still the drug
chart belongs to (name), with documented allergy to (drug). Intravenous fluid
therapy, prescribed today, (fluid, volume, rate/time) by (prescriber’s name) with
bleep number ###, batch number ###### commenced today at (time), given by
(name) and checked by (name). Finished today at (time). So I will check the IV
site ensuring that the the IV line is not there because it is already supposed to be
consumed. (If fluid is still ongoing) I will check the IV fluid level; this is (fluid) with
batch number ######, and expires on (date). Then I check that the rate of flow is
correct, will be consumed at (time), and the IV site is not showing signs of
complication such as phlebitis or infiltration and complete the Visual Infusion
Phlebitis score. I will not also give any IV medications because I am not yet IV
competent.
* Speed shock - a sudden adverse physiological reaction to IV medications or
drugs that are administered too quickly. Some signs of speed shock are a
flushed face, headache, a tight feeling in the chest, irregular pulse, loss of
consciousness, and cardiac arrest.
Proceed to DRUG NOT ADMINISTERED. This is the part of the drug chart where
I will document clearly and accurately all withheld or refused medication, reason
for non administration, date and time, and affix my name and signature.
(If drug is due your time) This is a complete prescription and it is due my time. I
will do hand rub first and look for (drug) in the drug trolley, checking the integrity
of the packaging and the expiration date. This packaging is intact, dry, and not
past expiry date which is on (date), which means that it is safe to give the drug to
the patient. I will place the appropriate dose of medication in a pot using a non-
touch technique and bring it to the patient with a glass of water. Patient should
also be in an upright or sitting position when taking medications, if possible.
However, a side-lying position may also be used if the patient is unable to sit.
“Have you (taken/been taking) this medication before? Do you have any difficulty
in swallowing?” Explain the use and potential side effects of the medication to the
patient. If needed, demonstrate the use of the British National Formulary (BNF)
in finding and understanding the indication, normal dosage, side effects,
precautions, and contraindications of the drug. It is important to witness that the
patient has taken the medication then documenting administered medicine
clearly, accurately, and immediately. Any withheld or refused medication will need
to be documented in the same manner using the codes for non administration.
(If drug is a controlled drug) In the event that a controlled drug needs to be given,
it should be kept in a controlled drug cupboard and secured with a key, two
practitioners must be involved in the administration procedure, and then recorded
properly in the controlled drug record book. Since (drug) is a controlled drug, I
should check the patient after for effectiveness and/or toxicity.
(If previous nurse has not given the dose) Nurse (name) has not given the drug
due at (time) using code number # which meant that (reason for non-
administration). It is not due my time but I will still have to check with the
prescriber if they are happy to give the drug right now.
(If start date is tomorrow) The start date is not until tomorrow, so I will not give
this drug.
Page 4 of 18
 (Illegible/incomplete prescription) This is an (illegible/incomplete) prescription; I
will not administer this drug even if it is due. I will write code number 6 which
stands for illegible or incomplete prescription. I will speak to the prescriber and
request that the prescription is rewritten correctly.

(If a colleague administers a drug even if it’s not supposed to be given) This drug
is not supposed to be given because of (reason), however, my colleague (name)
has given it so I should escalate this matter to the senior nurse.

(IV medications/fluids) For meds, choose PO if it is an option. This is an IV

(medication/fluid) and since I am not yet IV competent, I am not allowed to give
it. I will ask one of my colleagues who is IV competent to administer this drug
since it is due, and I can be the second checker. But for now, I will not write
anything yet on this space, but make sure it is signed after administration. I will
also monitor (the patient’s response/the IV site for signs of complications) and
escalate accordingly.

(If you accidentally dropped the medication) I am aware that I have dropped the
medication so for safety purposes, I will pick it up after my drug rounds and
dispose it into the sharps bin.

Give pain relievers according to strength.

Check BP before administering anti-hypertensives.

Check pulse before giving digoxin (hold if PR <60 bpm).

Check RR before giving morphine (risk for respiratory depression).

Assess patient’s condition and consider if it is appropriate to administer or

withhold the drug, such as in situations when the patient has reduced conscious
level, unable to swallow safely, or has nausea and/or vomiting, meaning that an
oral medication would not be effective.

11. 5 AFTER’S
“Alright (name), thank you very much for your active participation. Do you have
any more questions or concerns?”

“Here is the call bell. Use it if you need any assistance by pressing this button.
And if you notice any reaction that may be related to the medications, please let
us know immediately.”

“Are you comfortable?” (If no) “Let me assist you to a more comfortable position.
Is that better? Would you like your side rails to be raised? Is there anything else I
can help you with?” We then ensure that the bed is in its lowest level, everything
the patient needs including his assistive devices are accessible and within reach.

Then I will do infection control including hand washing and cleaning the drug
trolley, ensure that medications are stored appropriately and secured safely,
complete documentation accurately and escalate any problem encountered
accordingly.

Page 5 of 18
 ASEPTIC NON-TOUCH TECHNIQUE (ANTT)
1. S AFETY
First, I will assess that the scene is safe, there are no wires or water spillages
that may cause any trips or slips. I will also make sure that the windows are
closed, fans are turned off, and no cleaning or bed making has been done 30
minutes prior to the procedure. This is to allow airborne organisms to settle
before exposing the sterile field (the wound). The patient should have also been
given pain relievers 20-30 minutes prior to the procedure, if prescribed.
2. P RIVACY
Next, I will draw the curtain close to ensure my patient’s privacy and dignity,
making minimal disturbance to prevent airborne contamination of the sterile field.
###### (MRN ######). Thank you. I have already prepared the necessary
materials for your wound dressing, are you still happy to continue with this
procedure? Do you have any questions or concern before we start? (If none)
Alright, let me assist you into a comfortable position.”
Raise or lower the bed to the appropriate height to ensure appropriate manual
handling and easy access to bed area and trolley.
10. PROCEDURE
Then I will do another hand rub and put on clean gloves. “Alright (name), I will
now loosen the dressing; let me know if you are feeling uncomfortable or if you
are in any pain, alright?” Then discard the clean gloves accordingly and do
another hand rub.

3. H ANDWASHING Now, I will start opening the sterile packs as close to the patient as possible,
Now, I will perform hand washing according to the World Health Organization carefully sliding the contents, without touching them, onto the top shelf of the
Guidelines. trolley. Open the sterile field using only the corners of the paper.

a. Open the tap and wet my hands. Then, I will use this plastic disposal bag as a ‘sterile’ glove to arrange all items on
b. Apply soap. the sterile field. After that, I will remove the old dressing from the wound. Now is
c. Rub palm to palm. the best time to assess the wound for any sign of inflammation or infection (and
d. Palm over dorsum with interlaced fingers. perform a wound swab for any suspicion of infection). Then carefully invert the
e. Palm to palm with fingers interlaced. bag and stick it to the trolley below the top shelf, near the patient.
f. Fingers interlocked.
g. Thumbs. Then do another hand rub and open any other packs, and tip the contents gently
h. Fingertips. onto the centre of the sterile field. Use alcohol swab to clean the end of the
i. Wrists. packet of the saline solution pack and allow to dry before opening it.
j. Rinse.
k. Close the tap using my elbows. Now, I will wash my hand again using the World Health Organization guidelines.
l. Dry my hands thoroughly, using paper towels, from fingertips to wrists. Don on the sterile gloves and place this sterile towel under the dressing site.
m. Dispose the towel into the black bin or according to Trust Policy.
As I have maintained the sterility of my gloved hands, I now establish that my left
4. G REET hand is my clean hand and my right hand is my dirty hand. My clean hand will
I am now ready to approach my patient. “Hello, Mr/Ms/Mrs (name), my name is stay in the sterile field and my dirty hand will come in contact with the patient and
(your name), I am the nurse looking after you today. How would you like me to is near the disposal bag. Folding the gauze triangularly, I use my clean hand to
call you?” dip it in cleaning solution, squeeze, transfer onto my dirty hand, wipe in a single
stroke, then discard. Repeat until 4th gauze (center, side, side, center). The last
5. I DENTITY piece of gauze will be used to pat dry the wound. Then apply appropriate
“May I check your wrist band? Can you tell me your full name? And date of birth dressing.
please? And your MRN number is ###### (MRN ######). Thank you.” I have
confirmed that I am with the right patient. I will also check the documentation or 14. POST-PROCEDURE
wound care plan beforehand to verify the recommended procedure, dressing to “Alright (name), thank you very much for your active participation. How are you
be used, and date when due. feeling? Do you have any questions or concerns?”

6. A LLERGIES
“I can see that you have a red wrist tag on, what are you allergic to? What is your
reaction when you take (allergen)?”
7. L ATEX ALLERGY
“Do you have a reaction to latex or rubber products? (If yes) What kind of
reaction do you have?”
“I will make sure to document your allergy to (drug); rest assured that during your
stay here in the hospital, you will not receive any (drug/drug-based/latex or
rubber products).”
8. GAIN CONSENT
“Alright (name), at this moment, I will be discussing with you wound dressing,
which we will undertake in a while. Is this a good time to carry on with the
explanation? So, I will change the dressing of your wound using the aseptic non-
touch technique, which minimises the risk of cross contamination and therefore,
infection. Have you been given any pain relievers in the last 20-30 minutes? Has
it taken effect? Are you happy to continue with it? Do you have any questions or
concerns? (If none) Alright, let me just prepare the materials needed for the
procedure. In the meantime, here is the call bell; press this orange button in case
you need anything while I am away and I or my colleagues will be with you as
soon as we can. Would you like your side rails to be raised?”
“Here is the call bell. Use it if you need any assistance or have any concern
related to the procedure by pressing this button and we will be with you as soon
as we can. Please do let us know if you feel any pain or notice discharges from
the wound, alright?”
“Are you comfortable?” (If no) “Let me assist you to a more comfortable position.
Is that better? Would you like your side rails to be raised? Is there anything else I
can help you with?” We then ensure that the bed is in its lowest level, everything
the patient needs including his assistive devices are accessible and within reach.
Then I will do infection control including hand washing, disposal of the clinical
waste into the clinical waste bin or according to Trust Policy, and clean the trolley
using the same techniques as before. Document the procedure accurately
including my name as the person who carried out the procedure, the dressing
used, solution used for cleansing (normal saline), and date when next due (2-3
days or if condition changes). I will also escalate any problem encountered
accordingly.

9. PRE-PROCEDURE
First, I will perform hand washing and wear apron and gloves to prepare the
trolley. Ideally, the trolley must be cleaned using soap and water every 24 hours,
and antimicrobial wipes between each procedure. Use an S-motion technique
starting from front to back covering all edges, then dispose wipes. Grab new
antimicrobial wipes and start cleaning the legs of the trolley in a rotating motion,
from top to bottom, discarding and changing wipes after each trolley leg.
Continue cleaning the bottom shelf using the same technique as with the top
shelf, still covering all edges. Let the trolley dry; remove my apron and gloves
and dispose it to the clinical waste bin or according to Trust Policy, and perform
hand rub as I would my hand washing.

I will now prepare the necessary materials needed for the procedure, making
sure that each is dry, intact, and not past expiry date. These should all be placed
on the bottom shelf ready for use. Verbalize “DRY, INTACT, and NOT PAST
EXPIRY DATE which is on (date)” for every thing (sterile dressing pack,
appropriate dressing, normal saline solution, alcohol swab, hand gel, clean
gloves, wound swabs [if needed]).

Now, I will do another hand rub and don a new plastic apron. I will now approach
the patient’s bedside along with the trolley, making minimal disturbance to the
curtain as possible.

“Hello again (name), my name is (your name). May I check your wrist band? Can
you tell me your full name? And date of birth please? And your MRN number is
Page 6 of 18
 BASIC LIFE SUPPORT 11. AFTER HANDOVER
a. Hand washing.
1. Repeat the situation back to the assessor to confirm understanding. b. Document event in the patient’s and resuscitation notes, including the time
when patient was found unresponsive, the start time of compressions, end time
2. SAFETY of compressions, and time of revival/death.
Check for any danger; is the scene safe for me to enter?
Time is an essential element for successful CPR. The immediate initiation of
3. PRIVACY CPR can double or quadruple survival from cardiac arrest.
Draw the curtain close for privacy.

3. HAND HYGIENE/PPE
If I have time, I will do hand washing and put on personal protective equipment,
but since this is an emergency situation, I will just do a quick hand rub following
the same technique as hand washing.

4. RESPONSIVENESS
“Hey, are you OK?” The patient is unresponsive. “HELP!” Pull the emergency call
button.

5. CPR
Expose the chest, open the mouth and check for obstructions, open the airway
using the head-tilt-chin-lift maneouver, and look, listen, and feel for normal
breathing for 10 seconds.

There are no signs of life. I will now start chest compressions. (If help has
arrived) Please dial double-2, double-2, ask for the Adult Resus Team and tell
them we have a cardiac arrest patient here, and come back with a bag-valve-
mask and the resus trolley.

Continue chest compressions until help has arrived with the bag-valve-mask.
Please connect the bag to the oxygen source at 15 litres, open the patient’s
airway using the head-tilt-chin-lift maneouver, and place the mask securely over
the mouth and nose and make a tight seal. Ready? I will now deliver 2 rescue
breaths, observing for the rise and fall of the chest then start 30 compressions to
2 breaths.

6. HANDOVER
Hi, I am (your name), I am not a nurse in this ward and I will now do an SBAR
handover.

a. The SITUATION is that (scenario) and I noticed that the patient is looking very
unwell so I tried to wake (him/her) up.

b. I do not have a BACKGROUND on this patient because I do not know (him/

her).

c. For the ASSESSMENT, he is unresponsive so I called for help and pulled the
emergency button. I then exposed the patient’s chest, opened the mouth and
check for obstructions, opened (his/her) airway using the head-tilt-chin-lift
maneouver, and looked, listened, and felt for normal breathing for 10 seconds.
He had no signs of life so I placed the heel of my hand on the centre of the chest
and started chest compressions at a rate of 100-120 compressions per minute,
depth of 5-6 cms, allowing full chest recoil with minimal interruptions. When help
arrived, I asked (him/her) to dial double-2, double-2, ask for the Adult Resus
Team and tell them we have a cardiac arrest patient here, and come back with a
bag-valve-mask and the resus trolley. When the mask is connected to the
oxygen source at 15 litres and secured tightly over the patient’s mouth and nose
while maintaining an open airway, I delivered 2 rescue breaths, observing for the
rise and fall of the chest. Then I started 30 chest compressions to 2 rescue
breaths. In total, I delivered (3) cycles of 30 compressions to 2 breaths.

d. When patient is revived, the RECOMMENDATION is for him to be transferred

to the Intensive Unit and perform tests to determine the cause of cardiac arrest.

7. HIGH QUALITY CHEST COMPRESSIONS

a. Rate of 100-120 compressions per minute.
b. Depth of 5-6 centimetres.
c. Allow full chest recoil.
d. Minimise interruptions.

8. CAUSES OF ARREST (4 H’s AND 4 T’s)

a. Hypoxia
b. Hypovolemia
c. Hypothermia
d. Hypo-/hyper- kalaemia
e. Thrombosis (coronary or pulmonary)
f. Toxicity (poisoning or drug intoxication)
g. Tamponade (cardiac)
h. Tension Pneumothorax

9. WHEN TO DISCONTINUE RESUSCITATION

a. The patient is showing signs of life.
b. Resus Team/further qualified help has arrived.
c. The rescuer is exhausted.
d. The scene is no longer safe.

10. DIFFERENCE IN PAEDIA RESUSCITATION

a. The usual cause of arrest is respiratory.
b. Give 5 initial rescue breaths before starting chest compression.
c. Ratio is 15 compressions to 2 breaths.

Page 7 of 18
 INJECTIONS
1. S AFETY
First, I will assess that the scene is safe, there are no wires or water spillages
that may cause any trips or slips.
2. P RIVACY
Next, I will draw the curtain close to ensure my patient’s privacy and dignity.
3. H ANDWASHING
Now, I will perform hand washing according to the World Health Organization
Guidelines.
a. Open the tap and wet my hands.
b. Apply soap.
c. Rub palm to palm.
d. Palm over dorsum with interlaced fingers.
e. Palm to palm with fingers interlaced.
f. Fingers interlocked.
g. Thumbs.
h. Fingertips.
i. Wrists.
j. Rinse.
k. Close the tap using my elbows.
l. Dry my hands thoroughly, using paper towels, from fingertips to wrists.
m. Dispose the towel into the black bin or according to Trust Policy.
4. G REET
I am now ready to approach my patient. “Hello, Mr/Ms/Mrs (name), my name is
(your name), I am the nurse looking after you today. How would you like me to
call you?”
5. I DENTITY
“I will just do an identity check. Can you tell me your full name? And date of birth
please? And what is your address? Thank you.” I then check that this
prescription chart belongs to the same patient whose full name is (name), date of
birth (dd/mm/yyyy), and address is (address). I am happy to confirm that I am
with the right patient and I have the right prescription chart.
6. A LLERGIES
“Would you happen to know if you are allergic to any food or medication? What is
your reaction when you take (allergen)?”
7. L ATEX ALLERGY
“Do you have a reaction to latex or rubber products? (If yes) What kind of
reaction do you have?”
“I will make sure to document your allergy to (drug); rest assured that you will not
receive any (drug/drug-based/latex or rubber products).”
8. GAIN CONSENT
“Alright (name), at this time I will be administering (drug) through the
(intramuscular/subcutaneous) injection route. Are you happy for me to continue
with it? Do you have any allergic reaction to this drug? Have you been given this
medication before?” Explain the use and potential side effects of the medication
to the patient. “Do you have any bleeding disorder/recent surgery or lymph node
removal/fistula? Are you currently taking anticoagulant medications?”
9. PRE-PROCEDURE
“Do you have any questions or concerns? (If none) Alright, let me just prepare
the materials needed for the procedure. Just give me a shout in case you need
anything while I am away and I will be with you as soon as I can, alright?”
Before administering any prescribed drug, I will adhere to the 5 rights of
medication administration: right PATIENT, right DRUG, right DOSE, right
ROUTE, and right DATE AND TIME of administration. I will also check that the
prescription is valid and legible, and that the medication does not provide an
allergy for the patient.
Read the prescription. I am happy that this is a complete prescription.
I will now do hand rub as I would do hand washing and don an apron.
Then, I will prepare the necessary materials for this procedure, making sure that
each is dry, intact, and not past expiry date where appropriate. Materials needed
including withdrawing and injecting needles, syringes, and alcohol swabs, sterile
gauze, a sharps container, and a clean tray or receiver in which to place drug
and equipment.
Now, I will then do another hand rub and put on clean gloves. Check the drug
with the assessor as the second checker. I will check the drug against the
prescription chart, selecting the appropriate volume, dilution, or dosage to reduce
wastage, ensuring as well that the packaging is dry, intact, and not past expiry
date which is on (date), and batch number is (######). Also inspect the (solution/
powder) for any cloudiness, particulate matter, or discoloration. I will then open
this packaging and use the withdrawing needle to draw up required volume of the
drug, replace the sheath on the needle using one-handed scooping method and
expel air; remove the withdrawal needle, dispose it to the sharps container, and
replace it with the appropriate injecting needle.
I am now ready to approach the patient’s bedside along with the tray/receiver.
9. PROCEDURE
“Hello again (name), my name is (your name). I have already prepared the
necessary materials for your (intramuscular/subcutaneous) injection, are you still
happy to continue with this procedure? I will just do an identity check again. Can
you tell me your full name? And date of birth please? And what is your address?
Thank you.”
“Do you have any questions or concern before we start? (If none) Alright, let me
assist you into a comfortable position.” Positioning is important to allow access to
the injection site (if IM) and to ensure the designated muscle group is flexed and
therefore relaxed.
Now, I will do another hand rub and expose the injection site and assess for
signs of inflammation, oedema, infection, and skin lesions. It is important to keep
in mind to rotate sites of injection (to prevent formation of indurations or
abscesses, and to reduce pain). Then, I will do hand rub again as I would do my
hand wash, and apply clean gloves.
10. INTRAMUSCULAR
For intramuscular injection, I will be using a 21/23 G needle for injection. Clean
the injection site, in this case 2.5 cm down from the acromion process in the
deltoid site, with an alcohol swab for 30 seconds and allow to dry for 30 seconds.
Using my non-dominant hand, I will stretch the skin slightly around the injection
site, then hold the syringe with the medication like a dart with my dominant hand.
“I will now inject the needle; you will feel a sharp scratch, alright?” Then quickly
plunge the needle at an angle of 90° with the bevel facing upward into the skin
until about 1 cm of the needle is left showing, pull back the plunger to check the
position of the needle. If no blood is aspirated, depress the plunger and inject the
drug slowly at a rate of approximately 1 ml every 10 seconds. I will then wait for
another 10 seconds before withdrawing the needle from the site.
Afterwards, I will withdraw the needle rapidly, continuing the traction until the
needle has been removed, place sharps into the sharps bin immediately, apply a
gentle pressure using a sterile gauze to any bleeding, but not massaging the
area. I will also apply a small plaster over the puncture site if the patient is not
allergic to it.
11. SUBCUTANEOUS
For subcutaneous injection, I will be using a 25 G needle for injection. Clean the
injection site, in this case the posterior aspect of the lower part of the upper arm,
with alcohol swab. Using my non-dominant hand, I will gently pinch the skin up
into a fold, then hold the syringe with the medication like a dart with my dominant
hand. “I will now inject the needle; you will feel a sharp scratch, alright?” Insert
the needle into the skin at an angle of 45°, release the grasped skin (unless
administering insulin when an angle of 90° should be used), and inject the drug
slowly over 10–30 seconds.
Afterwards, I will withdraw the needle rapidly, apply a gentle pressure using a
sterile gauze, but not massaging the area.
12. POST-PROCEDURE
“Alright (name), thank you very much for your active participation. How are you
feeling? Do you have any questions or concerns?”
“(Name), pain on the injection site is normal and expected; however, if you start
developing difficulty of breathing or rashes, please contact or general practitioner
(GP) immediately and call triple-9 for the ambulance.”
“Are you comfortable?” (If no) “Let me assist you to a more comfortable position.
Is that better? Is there anything else I can help you with?” We then ensure that
the bed is in its lowest level, everything the patient needs including his assistive
devices are accessible and within reach.
Then I will do infection control including hand washing and disposal of sharps
into the sharps container and non-sharp waste into the clinical waste bin or
according to Trust Policy, and clean the tray/receiver appropriately. Document
the administration accurately on appropriate charts and observe for possible
reactions or injection complications. I will also escalate any problem encountered
accordingly.
13. DOCUMENTATION
Introduce self to (name) and (name) consented to the procedure.
(Name) tolerated the procedure well.
(Name) verbalised understanding of the health teaching provided.
Page 8 of 18
 PEAK FLOW The patient should repeat the procedure three times with a moment to rest in
between each, with the best of the three results documented along with the
1. S AFETY specific time and any previous medication.
First, I will assess that the scene is safe, there are no wires or water spillages
that may cause any trips or slips. 11. POST-PROCEDURE
“Alright (name), thank you very much for your active participation. Do you have
2. P RIVACY any questions or concerns?”
Next, I will draw the curtain close to ensure my patient’s privacy and dignity.
“Here is the call bell. Use it if you need any assistance by pressing this button
3. H ANDWASHING and we will be with you as soon as we can.”
Now, I will perform hand washing according to the World Health Organization
Guidelines. “Are you comfortable?” (If no) “Let me assist you to a more comfortable position.
Is that better? Would you like your side rails to be raised?” We then ensure that
a. Open the tap and wet my hands. the bed is in its lowest level, everything the patient needs including his assistive
b. Apply soap. devices are accessible and within reach.
c. Rub palm to palm.
d. Palm over dorsum with interlaced fingers. Then I will do infection control including hand washing, disposal of the
e. Palm to palm with fingers interlaced. mouthpiece in line with local policies, and cleaning the meter. Then document the
f. Fingers interlocked. readings on the patient’s record chart, comparing measured values against
g. Thumbs. predicted values or patient trends and report any abnormality to medical or
h. Fingertips. senior nursing staff. I will also escalate any problem encountered accordingly.
i. Wrists.
j. Rinse.
k. Close the tap using my elbows.
l. Dry my hands thoroughly, using paper towels, from fingertips to wrists.
m. Dispose the towel into the black bin or according to Trust Policy.

4. E QUIPMENT CHECK
Then, I will check that my equipment are clean, well-calibrated, and within the
service date. Before the procedure is performed, I should make sure that the
patient is rested unless otherwise specified.

5. G REET / GAIN CONSENT

I am now ready to approach my patient. “Hello, Mr/Ms/Mrs (name), my name is
(your name), I am the nurse looking after you today. How would you like me to
call you? Alright (name), I have been asked to do a peak flow measurement with
you, is that alright?”

6. I DENTITY
“May I check your wrist band? Can you tell me your full name? And date of birth
please? And your MRN number is ###### (MRN ######). Thank you.” I have
confirmed that I am with the right patient.

7. A LLERGIES
“I can see that you have a red wrist tag on, what are you allergic to? What is your
reaction when you take (allergen)?”

8. L ATEX ALLERGY
“Do you have a reaction to latex or rubber products? (If yes) What kind of
reaction do you have?”

“I will make sure to document your allergy to (drug) so rest assured that during
your stay here in the hospital, you will not receive any (drug/drug-based/latex or
rubber products).”

“Do you have any concerns before we start the assessment?”

9. PRE-PROCEDURE
“Have you performed peak flow before? (If yes) What have been your best peak
flow measurements? What are your current peak flow readings? (If no) Alright, so
peak expiratory flow is used to measure the degree of air flow limitation,
especially with asthma patients, and can help monitor efficacy of treatment and
progression of condition. It involves exhaling as quickly and forcefully as possible
following maximal inspiration through this peak flow meter and the maximum
expiratory flow is expressed in litres per minute.” Patients should also have the
opportunity to have the procedure demonstrated for them and have their own
practice attempts before doing actual readings.

“Do you have your own meter with you and would you like to use it?” If using the
patient’s own meter, we make sure it is in good working condition as different
equipment might have slight variations in results. Inaccuracy with the spring
becoming slack over time can also be a problem so the meter preferably should
be less than a year old. If using a multiple patient use device, we ensure that is is
valved and has a disposable single patient use mouthpiece.

Then we ask the patient if they perform peak flow standing up or sitting down.
This ensures that there is no positional obstruction which could affect the results.
It is also advisable that the patient uses the same posture each time to increase
reliability and enable comparisons. “Alright, in which position (sitting upright/
standing) do you normally undertake this procedure? Please remember not to
flex your neck.”

Then we push the needle on the gauge down to zero to ensure accurate results
and get ready for the procedure.

10. PROCEDURE
So we ask the patient to hold the peak flow meter horizontally, ensuring their
fingers do not impede the gauge, then to take a deep breath in through their
mouth to full inspiration. Then immediately place their lips tightly around the
mouthpiece and blow out through the meter in a short sharp ‘huff’ as forcefully as
they can.

Page 9 of 18
 URINARY CATHETERISATION
1. S AFETY
First, I will assess that the scene is safe, there are no wires or water spillages
that may cause any trips or slips. I will also make sure that the windows are
closed, fans are turned off, and no cleaning or bed making has been done 30
minutes prior to the procedure. This is to allow airborne organisms to settle
before exposing the sterile field (the patient’s genital area). The patient should
have also been given pain relievers 20-30 minutes prior to the procedure, if
prescribed.
2. P RIVACY
Next, I will draw the curtain close to ensure my patient’s privacy and dignity,
making minimal disturbance to prevent airborne contamination of the sterile field.
3. H ANDWASHING
Now, I will perform hand washing according to the World Health Organization
Guidelines.
a. Open the tap and wet my hands.
b. Apply soap.
c. Rub palm to palm.
d. Palm over dorsum with interlaced fingers.
e. Palm to palm with fingers interlaced.
f. Fingers interlocked.
g. Thumbs.
h. Fingertips.
i. Wrists.
j. Rinse.
k. Close the tap using my elbows.
l. Dry my hands thoroughly, using paper towels, from fingertips to wrists.
m. Dispose the towel into the black bin or according to Trust Policy.
4. G REET
I am now ready to approach my patient. “Hello, Mr/Ms/Mrs (name), my name is
(your name), I am the nurse looking after you today. How would you like me to
call you?”
5. I DENTITY
“May I check your wrist band? Can you tell me your full name? And date of birth
please? And your MRN number is ###### (MRN ######). Thank you.” I have
confirmed that I am with the right patient.
6. A LLERGIES
“I can see that you have a red wrist tag on, what are you allergic to? What is your
reaction when you take (allergen)?”
7. L ATEX ALLERGY
“Do you have a reaction to latex or rubber products? (If yes) What kind of
reaction do you have?”
“I will make sure to document your allergies; rest assured that during your stay
here in the hospital, you will not receive any (drug/drug-based/latex or rubber
products).”
8. GAIN CONSENT
“Alright (name), at this moment, I will be discussing with you a procedure called
urinary catheterisation, which we will be undertaking in a while. Is this a good
time to carry on with the explanation? So, urinary catheterisation is the insertion
of a specially designed tube into the bladder using aseptic technique (for the
purposes of draining urine, removing of clots/debris, or instilling medication). It is
quite invasive and a little uncomfortable for you. Are you happy to continue with
it? Have you been given any pain relievers in the last 20-30 minutes? Has it
taken effect? Do you have any questions or concerns? (If none) Alright, let me
just prepare the materials needed for the procedure. Here is the call bell; press
this orange button in case you need anything while I am away and I or my
colleagues will be with you as soon as we can. Would you like your side rails to
be raised?”
9. PRE-PROCEDURE
First, I will perform hand washing and wear apron and gloves to prepare the
trolley. Ideally, the trolley must be cleaned using soap and water every 24 hours,
and antimicrobial wipes between each procedure. Use an S-motion technique
starting from front to back covering all edges, then dispose wipes. Grab new
antimicrobial wipes and start cleaning the legs of the trolley in a rotating motion,
from top to bottom, discarding and changing wipes after each trolley leg.
Continue cleaning the bottom shelf using the same technique as with the top
shelf, still covering all edges. Let the trolley dry; remove my apron and gloves
and dispose it to the clinical waste bin or according to Trust Policy, and perform
hand rub as I would my hand washing.
I will now prepare the necessary materials needed for the procedure, making
sure that each dry, intact, and not past expiry date. These should all be placed
on the bottom shelf ready for use. Verbalize “DRY, INTACT, and NOT PAST
EXPIRY DATE which is on (date)” for every thing (sterile pack, disposable pad,
normal saline solution, hand gel, sterile gloves, sterile water, appropriate
catheter, syringe and needle [for obtaining sample], sterile anesthetic lubricating
jelly, plastic apron, universal specimen container, drainage bag, clean towel, and
orange clinical waste bag).
Now, I will do another hand rub and don a new plastic apron. I will now approach
the patient’s bedside along with the trolley, making minimal disturbance to the
curtain as possible.
“Hello again (name), my name is (your name). May I check your wrist band? Can
you tell me your full name? And date of birth please? And your MRN number is
###### (MRN ######). Thank you. I have already prepared the necessary
materials for your urinary catheterisation, are you still happy to continue with this
procedure? Do you have any questions or concern? Hand rub. (If none) Alright,
let me assist you into a supine position (if male) with legs extended on the bed
OR (if female) with knees bent, hips flexed, and feet resting about 60 cms apart.
We will then remove your trousers and use this towel to cover you while I
prepare the sterile field.
10. PROCEDURE
Then I will do another hand rub. Open the outer cover of the catheterisation pack
and slide the pack onto the top shelf of the trolley. Using aseptic technique,
carefully open the inner pack by its edges. Open any other pack, pour saline
solution into the gallipot (use alcohol swab to clean the end of the packet and
allow to dry before opening it), and open an appropriately sized catheter onto the
sterile field.
I will now remove the cover from the patient’s genital area, maintaining patient’s
privacy, and position this disposable pad under the patient’s buttocks and thighs.
Hand rub.
I will now put on sterile gloves on my hands and place the catheter into the sterile
receiver. Then pick up these sterile sheets and apply it (if male) across the
patient’s thighs OR (if female) under the buttocks to create a sterile field.
11. MALE
Then with one hand, I will wrap a sterile gauze around the penis and use this to
retract the foreskin, if necessary, and with the other hand clean the glans penis
with 0.9% sodium chloride or sterile water. Then insert the nozzle of the
lubricating jelly into the urethra, squeeze the gel into the urethra, remove the
nozzle and discard the tube. Massage the gel along the urethra using the barrel
of the syringe; squeeze the penis and wait approximately 5 minutes to allow the
anesthetic gel to take effect.
With one hand hold the penis firmly behind the glans, raising it until it is almost
totally extended. Maintain this hold of the penis until the catheter is inserted and
urine is flowing. Then place the receiver containing the catheter between the
patient’s legs. I will now start inserting the catheter into the urethra for
approximately 15-25 cm until urine flows, then advance the catheter almost to its
bifurcation (division into two branches or parts).
12. FEMALE
Using a sterile gauze, I will separate the labia minora so that the urethral orifice
is exposed. This hand should be used to maintain labial separation throughout
the procedure or until catheterisation is complete. Clean around the urethral
orifice using 0.9% sodium chloride using single, downward strokes. Then place a
small amount of the lubricating jelly/anaesthetic onto the tip of the catheter. Place
the catheter, in the sterile receiver, between the patient’s legs. I will now
introduce the tip of the catheter into the urethral orifice in an upward and
backward direction, and advance the catheter until 5-6 cm has been inserted. If
urine is present, advance the catheter 6-8 cm to prevent the balloon from
becoming trapped in the urethra once inflated.
13. PROCEDURE CONTINUATION
At this point, it is now safe to inflate the balloon using 10 mls of sterile water or
according to the manufacturer’s directions, having ensured that the catheter is
draining properly beforehand. I will then withdraw the catheter slightly and
connect it to the drainage system to ensure that the balloon is inflated and the
catheter is secure. Support the catheter with the stat lock provided, positioning
catheter in a way that promotes drainage by gravity.
Ensure that the catheter does not become taut when mobilising. (If male) Ensure
as well that the glans penis is dry and the foreskin is extended.
14. POST-PROCEDURE
After the procedure, I will assist the patient in replacing their underwear/trousers
and replace bed cover, ensuring that the area is dry. I will also measure the urine
output and obtain a specimen for laboratory examination, if required.
“Alright (name), thank you very much for your active participation. How are you
feeling? Do you have any questions or concerns?”
“Here is the call bell. Use it if you need any assistance or have any concern
related to the procedure by pressing this button and we will be with you as soon
as we can.”
“Are you comfortable?” (If no) “Let me assist you to a more comfortable position.
Is that better? Would you like your side rails to be raised?” We then ensure that
the bed is in its lowest level, everything the patient needs including his assistive
devices are accessible and within reach.
Then I will do infection control including hand washing, disposal of the clinical
waste into the clinical waste bin or according to Trust Policy, and clean the trolley
using the same techniques as before. Document the procedure accurately
including the reasons for catheterization, date and time of procedure, catheter
type, length and size used, amount of water instilled into the balloon, batch
number, manufacturer number, any problems talked through the procedure and a
review date to assess the need for continued catheterisation or date of change of
catheter. I will also escalate any problem encountered accordingly.
Page 10 of 18
COMMON DRUGS

DRUG CLASSIFICATION INDICATION DOSE SIDE EFFECTS CONTRA-INDICATION

susceptible infections (UTI, acute/ chronic lymphocytic

otitis media, sinusitis,
Penicillins (broad- uncomplicated CAP,
AMOXCILLIN
spectrum) salmonellosis), Lyme
diseasee, anthrax, dental
abscess
leukaemia, cytomegalovirus
500 mg every 8 nausea, vomiting; if rash infection, glandular infection
hours occurs, discontinue treatment (increased risk of erythematous
rashes), maintain adequate
hydration with high doses

acute/ chronic lymphocytic

susceptible infections (UTI,
Penicillins (broad- otitis media, sinusitis,
AMPICILLIN
spectrum) uncomplicated CAP,
salmonellosis)
leukaemia, cytomegalovirus
500 mg - 1 g every
nausea, vomiting infection, glandular infection
6 hours
(increased risk of erythematous
rashes)

CVD, management of
unstable angina and
Antiplatelet;
ASPIRIN NSTEMI/STEMI, TIA, acute
acetylsalicylic acid
ischemic stroke, mild to
moderate pain, pyrexia
75 - 300 mg daily
blood disorders, active peptic ulceration, bleeding
bronchospasm, confusion, GI disorders, <16 years (Reye’s
for pain/pyrexia:
haemorrhage, GI irritation, syndrome), haemophilia
300 - 900 mg every
increased bleeding time, skin hypersensitivity to aspirin or any
4-6 hours, max 4 g/
reactions, tinnitus other NSAID
day

history of asthma, bronchospasm, or

hypertension, angina,
Beta-adrenoceptor history of obstructive airway disease
arrhythmias, migraine
ATENOLOL blockers 25 - 200 mg daily dry eyes, rashes (*monitor lung function), cardiogenic
prophylaxis, early intervention
(systemic) shock, hypotension, marked
within 12 hours of MI
bradycardia, metabolic acidosis

history of asthma, bronchospasm, or

cramp, depression, muscle
Beta-adrenoceptor 5 - 10 mg once history of obstructive airway disease
hypertension, angina; adjunct weakness, hearing
BISOPROLOL blockers daily, max 20 mg/ (*monitor lung function), cardiogenic
in heart failure impairment, hyper-
(systemic) day shock, hypotension, marked
triglyceridaemia, conjunctivitis
bradycardia, metabolic acidosis

arrhythimas, bradycardia, fall

severe acute hypocalcaemia
or hypocalcemia tetany, acute
CALCIUM
Calcium salts severe hyperkalaemia,
GLUCONATE
calcium deficiency, mild
asymptomatic hypocalcaemia
in blood pressure, GI
disturbances,
10 - 20 ml calcium history of nephrolithiasis, sarcoidosis
hypercalcaemia, injection-sire
gluconate injection (disease involving abnormal
reactions, peripheral
10% (0.11 mmol/kg collections of inflammatory cells that
vasodilatation, severe tissue
is equivalent to 0.5 form lumps known as granulomas),
damage with extravasation,
ml/kg of calcium risk of arrhythmias if given too
sweating
gluconate 10% rapidly
* plasma-calcium and ECG
monitoring required

cholestasis; Afro-Caribbean patients

(particularly those with left
headache, vertigo;
Angiotensin-II ventricular hypertrophy), aortic or
hyperkalaemia, angioedema,
CANDESARTAN receptor hypertension 4 - 32 mg once daily mitral valve stenosis, elderly,
symptomatic hypotension
antagonists hypertrophic cardiomyopathy, history
including dizziness
of angioedema, primary
aldosteronism, renal artery stenosis

Macrolides RTI, mild to moderate skin 250 - 500 mg abdominal discomfort, pregnancy (1st trimester), caution in
CLARITHROMYCIN (erythromycin and soft-tissue infections, usually for 7 - 14 headache, hyperhidrosis, electrolyte disturbances, may
derivative) otitis media days insomnia, taste disturbances aggravate myasthenia graves

oral: 250/125 mg acute/ chronic lymphocytic

infections due to beta-
Penicillin (broad- lactamase-producing strains,
spectrum); including RTI, bone and joint
CO-AMOXICLAV
amoxicillin + infections, genitourinary and
clavulanic acid abdominal infections,
cellulitis, animal bites
every 8 hours, leukaemia, cytomegalovirus
increased to cholestatic jaundice, hepatitis, infection, glandular infection
500/125 mg every 8 nausea, vomiting; dizziness, (increased risk of erythematous
hours headache, prolonged rashes)
bleeding time
IV: 1.2 g every 8 *maintain adequate hydration with
hours high doses

abdominal pain, anorexia,

blood disorders, depression, active ulcerative colitis, antibiotic-
hypothermia, leucopenia, associated colitis, children <18
malaise, muscle fasciculation, years who undergo the removal of
8/500 - 16/1000 mg
Opioids; codeine neutronnia, pancreatitis, tonsils or adenoids for the treatment
mild to moderate pain, severe every 4-6 hours,
CO-CODAMOL phosphate + seizures, thrombocytopenia; of obstructive sleep apnoea,
pain max 64/4000 mg
paracetamol liver damage following conditions where abdominal
per day
overdosage with paracetamol distention develops, condition where
inhibition of peristalsis should be
*withdrawn gradually to avoid avoided
abstinence symptoms

Page 11 of 18
 DRUG CLASSIFICATION INDICATION DOSE SIDE EFFECTS CONTRA-INDICATION

active ulcerative colitis, antibiotic-

acute diarrhoea, mild to
moderate pain, short-term
CODEINE Opioids
treatment of acute moderate
pain, dry or painful cough
associated colitis, children <18
years who undergo the removal of
abdominal pain, anorexia,
tonsils or adenoids for the treatment
antidiuretic effect,
15 - 60 mg 3-4 of obstructive sleep apnoea and
hypothermia, malaise, muscle
times a day whose breathing may be
fasciculation, pancreatitis,
compromised, conditions where
seizures
abdominal distention develops,
condition where inhibition of
peristalsis should be avoided

drowsiness, anaphylaxis,
angioedema, angle-closure
avoid in acute porphyria (disorders
glaucoma, arrhythmias, blood
of haem biosynthesis characterised
disorders, bronchospasm,
by attacks of pain, hypertension,
confusion, convulsions,
nausea, vomiting, vertigo, signs of neurological distress,
Antihistamines, 50 mg up to 3 times depression, dizziness,
CYCLIZINE motion sickness, labyrinthine abdominal pain, vomitng,
antiemetics a day extrapyramidal symptoms,
disorders constipation, breathing difficulties,
hypotension, liver
reddish-colored urine), neonates,
dysfunction, palpitation,
epilepsy, glaucoma, may counteract
photosensitivity reactions,
hemodynamics benefits of opioids
rashes, sleep disturbances,
tremor

susceptible infections, acne,

rosacea, early syphilis,
DOXYCYCLINE Tetracyclines
chlamydia, pelvic
inflammatory disease
initially 200 mg daily
anorexia, anxiety, dry mouth, myasthenia gravis, SLE, alcohol
for 2 dose, then 100
flushing, tinnitus dependence
mg daily

hypertension, heart failure, initially 2.5 - 5 mg asthenia, blurred vision,

Angiotensin- prevention of symptomatic once daily, depression, dyspnoea enhanced hypotensive effect when
ENALAPRIL converting enzyme heart failure in patients with maintenance 20 mg given with alcohol, absorption
(ACE) inhibitors asymptomatic left ventricular once daily, max 40 *monitor renal function and possibly reduced by antacids
dysfunction mg per day electrolytes

constipation, diarrhoea,
epigastric pain, faecal
FERROUS SULFATE Iron supplements iron-deficiency anemia 200 mg *monitor haemoglobin concentration
impaction, GI irritation,
nausea

oedema, resistant anuria, renal failure, severe

FUROSEMIDE Loop diuretics 20 - 120 mg gout, intrahepatic cholestasis
hypertension hypokalaemia/ hyponatraemia

microcytic anaemia,
pernicious anaemia (with or
HYDROXO- should not be given before diagnosis
without neurological 1 mg every 3
COBALAMIN Vitamin B group dizziness, headache, pruritus fully established, response reduced
involvement), tobacco months
(VITAMIN B12) by chloramphenicol
ambylopia, Leber’s optic
atrophy

mild to moderate pain,

NSAIDs (anti- postoperative analgesia, pain
200 - 400 mg 3
inflammatory, and inflammation in alveolitis, aseptic meningitis, history of or active GI bleeding/
IBUPROFEN times a day
analgesic, rheumatic disease, soft-tissue SJS, visual disturbances ulceration, severe heart failure
(maintenance)
antipyretic) injuries, pyrexia with
discomfort

anginal pain, arrhythmias,

100 - 200 mpg once
diarrhoea, excitability, fever,
daily, taken thyrotoxicosis, caution for CV
flushing, headache, heat
preferably at least disorders, diabetes insidious,
intolerance, insomnia, muscle
LEVOTHYROXINE Thyroid hormones hypothyroidism 30 minutes before diabetes mellitus, elderly,
cramp/ weakness, oedema,
breakfast, caffeine- hypertension, myocardial infarction/
palpitation, pruritus, rash,
containing liquids, insufficiency
sweating, tachycardia, tremor,
or other medication
vomiting, weight loss

abdominal pain, agitation,

amenorrhoea, anorexia,
bronchospasm, delirium,
acute abdomen, acute respiratory
disorientation, hypertension,
depression (reversed by naloxone),
hypothermia, paraesthesia,
MORPHINE 5 - 10 mg every 4 comatose patients, delayed gastric
Opioids acute/ chronic pain paralytic ileum, raised ICP,
SULFATE hours emptying, head injury, heart failure
seizures, syncope, taste
secondary to CLD, raised ICP, risk
disturbances
of paralytic ileus
*withdrawn gradually to avoid
abstinence symptoms

Page 12 of 18
 DRUG CLASSIFICATION INDICATION
H. pylori eradication (in
combination with anti-
invectives), benign gastric
ulceration, duodenal
ulcerateion, prevention of
relapse in gastric/ duodenal
Proton pump
OMEPRAZOLE ulcer, NSAID-associated
inhibitors
duodenal/ gastric/
gastroduodenal erosions,
GORD, acid-reflux disease,
acid-related dyspepsia, major
peptic ulcer bleeding,
Zollinger-Ellison syndrome
moderately emetogenic
chemotherapy or
5HT3 receptor
ONDANSETRON radiotherapy, prevention and
antagonists
treatment of postoperative
nausea and vomiting
Analgesics; mild to moderate pain,
PARACETAMOL
acetaminophen pyrexia
major bleeding in patients on
warfarin, INR >8.0 with minor/
no bleeding in patients on
PHYTOMENADIONE warfarin, INR 5.0-8.0 with
Vitamin K
(VITAMIN K1) minor bleeding in patients on
warfarin, peri-operative
anticoagulation (after warfarin
stopped)
benign gastric ulceration,
chronic episodic dyspepsia,
NSAID-associated gastric/
H2-receptor
RANITIDINE duodenal ulceration, GORD,
antagonists
gastric acid reduction
(prophylaxis of acid
aspiration)
constipation (onset of action
SENNA Stimulant laxatives
8 - 12 hours)
treatment of supraventricular
Calcium-channel arrhythmias, paroxysmal
VERAPAMIL
blockers tachyarrhythmias, angina,
hypertension
prophylaxis of embolisation in
rheumatic heart disease and
atrial fibrillation, prophylaxis
after insertion of prosthetic
Vitamin K
WARFARIN heart valve, prophylaxis and
antagonists
treatment of venous
thrombosis and pulmonary
embolism, transient
ischaemic attacks
DOSE SIDE EFFECTS CONTRA-INDICATION
abdominal pain, agitation,
constipation, diarrhoea, can increase the risk of fractures
flatulence, GI disturbances, (particularly when used in high
headache, impotence, doses for over a year in the elderly,
10 - 80 mg rebound acid hypersecretion may increase risk of GI infection
and protracted dyspepsia (including C. diff infection), may
may occur after stopping mask symptoms of gastric cancer,
prolonged treatment with a patients at risk of osteoporosis
PPI, nausea, vomiting
8 - 24 mg
congenital long QT syndrome,
immediately or 1-2
constipation, flushing, caution in adenotonsillar surgery,
hours before
headache, injection-site subacute intestinal, susceptibility to
treatment, or 16 mg
reactions QT-interval prolongation (including
1 hour before
electrolyte disturbances)
anesthesia
acute generalized
exanthematous pustulosis,
malaise, skin reactions, SJS, alcohol dependence, chronic
0.5 - 1 g every 4-6 toxic epidermal necrolysis; alcoholism, chronic dehydration,
hours liver damage following chronic malnutrition, hepatocellular
overdosage (nausea and insufficiency
vomiting, the only early
features of poisoning)
IV injections should be given very
1 - 5 mg, stop
anaphylactoid reactions slowly due to risk of vascular
warfarin treatment
collapse
blurred vision, alopecia,
diarrhoea, dizziness,
headache, interstitial
nephritis, involuntary
150 - 300 mg twice movement disorders, caution in gastric cancer (might
daily pancreatitis, psychiatric mask symptoms)
reactions (including
confusion, depression, and
hallucinations) particularly in
the elderly or very ill
7.5 mg 2-4 tablets, abdominal cramp, excessive
or 10 - 20 ml once use can cause diarrhoea and
intestinal obstruction
daily; usually taken related effects such as
at night/ bedtime hypokalemia
acute porphyria (disorders of haem
biosynthesis characterized by
attacks of pain, hypertension, signs
of neurological distress, abdominal
pain, vomitng, constipation,
constipation; ankle oedema, breathing difficulties, reddish-colored
40 - 120 mg 3 times
dizzinessss, fatigue, flushing, urine), atrial flutter or fibrillation,
a day
headache, nausea, vomiting bradycardia, carcinogenic shock,
history of heart failure, history of
significantly impaired left ventricular
function, hypotension, second- and
third- degree AV block, sick sinus
syndrome, sino-atrial block
alopecia, diarrhoea,
haemorrhage, hepatic
avoid use within 48 hours
initially 5 - 10 mg, to dysfunction, jaundice,
postpartum (delay until risk of
be taken on day 1; nausea, pancreatitis, purpura,
hemorrhage is low - usually 5-7 days
subsequent doses pyrexia, rash, skin necrosis,
after delivery), haemorrhagic stroke,
dependent on vomiting, “purple toes”
significant bleeding; bacterial
prothrombin time,
endocarditis, history of GI bleeding,
reported as INR *avoid cranberry juice
peptic ulcer, recent ischaemic
(international *baseline prothrombin time
stroke, recent surgery, uncontrolled
normalised ratio) should be determined, then
hypertension
daily or on alternate days in
early days of treatment
Page 13 of 18
DRUGS AND THEIR ANTIDOTES

ANTIDOTE INDICATION MODE OF ACTION

Restores depleted glutathione stores and protects

Acetylcysteine (Mucomyst) Acetaminophen/ Tylenol/ Paracetamol
against renal and hepatic failure.

Non-specific poisons except cyanide, iron, lithium, Absorption of drug in the gastric and intestinal tracts.
Activated Charcoal
caustics and alcohol. Interrupts the entero-hepatic cycle with multiple dose.

Albuterol Inhaler, Insulin & Glucose, NaHCo3,

Potassium
Kayexalate

Anticholinesterase Agents Neuromuscular blockade (paralytics)

Atropine Sulfate or Pralidoxime Anticholinesterase Competitive inhibition of muscarinic receptors.

Not known; partial protection against acute hepatic

failure; may displace amatoxin from protein-binding
Benzylpenicillin Amanita phalloides (Death cap mushroom)
sites allowing increased renal excretion; may also
inhibit penetration of amatoxin to hepatocytes.

Calcium Salts Fluoride ingestion Rapidly complexes with fluoride ion.

Deferoxamine acts by binding free iron in the

Deferoxamine Iron
bloodstream and enhancing its elimination in the urine.

Digibind Binds molecules of digoxin, making them unavailable

Digoxin
Digoxine Immune Fab for binding at their site of action on cells in the body.

Chelation of lead ions and endogenous metals (e.g.,

Dimercapol, Edetate Calcium, Disodium Lead
zinc, manganese, iron, copper).

A potent antagonist to acetylcholine in muscarinic

Diphenhydramine (Benadryl) Extrapyramidal symptoms (EPS)
receptors.

Reverses the effects of benzodiazepines by competitive

Flumazenil Benzodiazepines inhibition at the benzodiazepine binding site on the
GABAA receptor.

A competitive inhibitor of the enzyme alcohol

dehydrogenase found in the liver. This enzyme plays a
Fomepizole Ethylene glycol
key role in the metabolism of ethylene glycol and
methanol.

Stimulates the formation of adenyl cyclase causing

intracellular increase in cycling AMP and enhanced
Glucagon Beta blockers and calcium channel blockers
glycogenolysis and elevated serum glucose
concentration.

Dextrose (the monosaccharide glucose) is used,

distributed and stored by body tissues and is
Glucose (Dextrose 50%) Insulin reaction
metabolized to carbon dioxide and water with the
release of energy.

Reverses hypercoagulable state by interacting with

antithrombin III. Used in combination with vasodilator
Heparin Ergotamine
phentolamine or nitroprusside to prevent local
thrombosis and ischemia.

Forms cyanocobalamin, a non-toxic metabolite that is

Hydroxocobalamin Cyanide
easily excreted through the kidneys.

Fluorouracil

Leucovorin Calcium Protects the healthy cells from the effects of

Methotrexate methotrexate while allowing methotrexate to enter and
kill cancer cells.

Magnesium Sulfate calcium gluconate

A “chemoprotectant” drug that reduces the undesired

Mesna Cyclophosphamide
effects of certain chemotherapy drugs.

Chemical producing severe methemoglobinemia. Reduces methemoglobin to hemoglobin.

Methylene Blue
Ifosamide-induced encephalopathy.

Prevents or reverses the effects of opioids including

Nalmefene or Naloxone Opioid analgesics
respiratory depression, sedation and hypotension.

Naloxone is believed to antagonize opioid effects by

Naloxone (Narcan) Narcotics competing for the µ, κ and σ opiate receptor sites in the
CNS, with the greatest affinity for the µ receptor.

Page 14 of 18
 ANTIDOTE INDICATION MODE OF ACTION

Anticholinesterase which causes accumulation of

Neostigmine Anticholinergics
acetylcholine at cholinergic receptor sites.

Oxidizes hemoglobin to methemoglobin which binds

Nitrite, Sodium, and Glycerytrinitrate Cyanide the free cyanide and can enhance endothelial cyanide
detoxification by producing vasodilation.

Penicillamine Copper, gold, lead, mercury, zinc, arsenic Chelation of metal ions.

Regitine produces an alpha-adrenergic block of

relatively short duration. It also has direct, but less
Phentolamine (Regitine) Dopamine marked, positive inotropic and chronotropic effects on
cardiac muscle and vasodilator effects on vascular
smooth muscle.

A reversible anticholinesterase which effectively

Phyostigmine Or Nahco3 Tricyclic antidepressants increases the concentration of acetylcholine at the sites
of cholinergic transmission.

Bypasses inhibition of Vitamin K epoxide reductase

Phytomenadione (Vitamin K.) Coumadin/Warfarin
enzyme.

Protamine that is strongly basic combines with acidic

Protamine Sulfate Heparin heparin forming a stable complex and neutralizes the
anticoagulant activity of both drugs.

Reverses acute pyridoxine deficiency by promoting

Isoniazid, theophylline, monomethyl hydrazine.
Pyridoxine GABA synthesis. Promotes the conversion of toxic
Adjunctive therapy in ethylene glycol poisoning.
metabolite glycolic acid to glycine.

Neutralizes venom by binding with circulating venom

Snake Anti-Venin Cobra bite components and with locally deposited venom by
accumulating at the bite site.

Iron Prevents convertion of ferrous to ferric.

Cardiotoxic drug affecting fast sodium channel (TCA, Decreases affinity of cardiotoxic drugs to the fast
cocaine) sodium channel.
Sodium Bicarbonate
Weak acids Promotes ionization of weak acids.

Neutralization of hydrochloric acid formed when

Chlorine gas inhalational poisoning
chlorine gas reacts with water in the airways.

Replenishes depleted thiosulphate stores by acting as

sulfur donor necessary for the conversion of CN-O to
Sodium Thiosulphate Cyanide
thiocyanate through the action of sulfur transferase
enzyme rhodanese.

Alcohol, Wernicke-Korsakoff Syndrome Reverses acute thiamine deficiency

Thiamine
Adjunctive in ethylene glycol Enhances detoxification of glyoxylic acid.

Chemicals causing methemoglobinemia in patients with Reduces methemoglobin to hemoglobin.

Vitamin C
G6PD deficiency

Page 15 of 18
COMMON INTERACTIONS (DRUG-FOOD-CONDITION) When using this product:
avoid alcoholic beverages
1. Taking some medicines at the same time as eating may prevent the stomach and
intestines absorbing the medicine, making it less effective. Alternatively, some d. Antihistamines (drugs that temporarily relieve runny nose or reduce
foods can interact with the medicine, either by increasing or decreasing the sneezing, itching of the nose or throat, and itchy watery eyes due to hay fever or
amount of medicine in the blood to potentially dangerous levels, or levels that are other upper respiratory problems)
too low to be effective. Some examples of foods or drinks which can interact with Ask a doctor or pharmacist before use if you are taking:
medicines include: sedatives or tranquilizers, or a prescription drug for high blood pressure or
depression
a. grapefruit juice Ask a doctor before use if you have:
b. cranberry juice glaucoma or difficulty in urination due to an enlarged prostate gland, or breathing
c. food high in vitamin K, such as leafy green vegetables problems, such as emphysema, chronic bronchitis, or asthma
d. salt substitutes or food supplements high in potassium, such as When using this product:
bananas alcohol, sedatives, and tranquilizers may increase drowsiness, and avoid
alcoholic beverages
2. Medications which should be taken on an EMPTY stomach:
e. Antitussives - Cough Medicine (drugs that temporarily reduce cough due to
Ampicillin minor throat and bronchial irritation as may occur with a cold)
Bethanechol Ask a doctor or pharmacist before use if you are:
Bisacodyl taking sedatives or tranquilizers
Captopril (take 1 hour before meals) Ask a doctor before use if you have:
Cilostazol (Pletal) glaucoma or difficulty in urination due to an enlarged prostate gland
Felodipine (Plendil) Ask a doctor before use if you:
Lansoprazole (take before eating) have heart disease, high blood pressure, thyroid disease, diabetes, or difficulty in
Levothyroxine urination due to an enlarged prostate gland, or have ever been hospitalized for
Loratadine (Claritin) asthma or are taking a prescription drug for asthma
Methotrexate
Omeprazole (take before eating) f. Laxatives (drugs for the temporary relief of constipation)
Oxacillin Ask a doctor before use if you have:
Penicillamine kidney disease and the laxative contains phosphates, potassium, or magnesium,
Perindopril (Aceon) or stomach pain, nausea, or vomiting
Rifampin
Sucralfate (Carafate) g. Nasal Decongestants (drugs for the temporary relief of nasal congestion due
Sulfamethoxazole - trimethoprim (Bactrim) to a cold, hay fever, or other upper respiratory allergies)
Sulfadiazine Ask a doctor before use if you:
Tetracycline (do not take with milk or other dairy products) have heart disease, high blood pressure, thyroid disease, diabetes, or difficulty in
urination due to an enlarged prostate gland
3. Medications which should be taken WITH FOOD:
h. Nicotine Replacement Products (drugs that reduce withdrawal symptoms
Allopurinol (take after meal) associated with quitting smoking, including nicotine craving)
Augmentin Ask a doctor before use if you:
Aspirin have high blood pressure not controlled by medication, or have heart disease or
Amiodarone (Cordarone) have had a recent heart attack or irregular heartbeat, since nicotine can increase
Baclofen (Lioresal) your heart rate
Carvedilol (Coreg) Ask a doctor or pharmacist before use if you are:
Carbamazepine (Tegretol) taking a prescription drug for depression or asthma (your dose may need to be
Chloroquine adjusted), or using a prescription non-nicotine stop smoking drug
Cimetidine (Tagamet) Do not use:
Diclofenac (Voltaren) if you continue to smoke, chew tobacco, use snuff, or use other nicotine-
Divalproex sodium (Depakote) containing products
Doxycycline
Fenofibrate (TriCor) i. Nighttime Sleep Aids (drugs for relief of occasional sleeplessness)
Glyburide (take with breakfast) Ask a doctor or pharmacist before use if you are:
Hydrocortisone taking sedatives or tranquilizers
Indomethacin Ask a doctor before use if you have:
Iron preparations (Take between meals--if GI upset occurs take with food) a breathing problem such as emphysema or chronic bronchitis, glaucoma, or
Ketorolac difficulty in urination due to an enlarged prostate gland
Metronidazole When using this product:
Mebendazole avoid alcoholic beverages
Methylprednisolone
Naproxen j. Pain Relievers (drugs for the temporary relief of minor body aches, pains, and
Nitrofurantoin headaches)
Niacin Ask a doctor before taking if you:
Pentoxifylline consume three or more alcohol-containing drinks per day
Piroxicam
Potassium salts k. Stimulants (drugs that help restore mental alertness or wakefulness during
Prednisone fatigue or drowsiness)
Spironolactone When using this product:
Valproic acid limit the use of foods, beverages, and other drugs that have caffeine. Too much
caffeine can cause nervousness, irritability, sleeplessness, and occasional rapid
4. Drug Interaction Information heart beat. Be aware that the recommended dose of this product contains about
a. Acid Reducers - H2 Receptor Antagonists (drugs that prevent or relieve as much caffeine as a cup of coffee.
heartburn associated with acid indigestion and sour stomach)
For products containing cimetidine, ask a doctor or pharmacist before use l. Topical Acne (drugs for the treatment of acne)
if you are: When using this product:
taking theophylline (oral asthma drug), warfarin (blood thinning drug), or increased dryness or irritation of the skin may occur immediately following use of
phenytoin (seizure drug) this product or if you are using other topical acne drugs at the same time. If this
occurs, only one drug should be used unless directed by your doctor.
b. Antacids (drugs for relief of acid indigestion, heartburn, and/or sour stomach)
Ask a doctor or pharmacist before use if you are:
allergic to milk or milk products if the product contains more than 5 grams lactose
in a maximum daily dose, or taking a prescription drug
Ask a doctor before use if you have:
kidney disease

c. Antiemetics (drugs for prevention or treatment of nausea, vomiting, or

dizziness associated with motion sickness)
Ask a doctor or pharmacist before use if you are:
taking sedatives or tranquilizers
Ask a doctor before use if you have:
a breathing problem, such as emphysema or chronic bronchitis, glaucoma,
difficulty in urination due to an enlarged prostate gland

Page 16 of 18
WEANING FROM OXYGEN THERAPY
1. Titrate or reduce oxygen therapy dose if the patient is clinically stable and the
oxygen saturation has been in the upper zone of the target range for some time
(usually 4-6 hours).
2. Observe the patient 5 minutes after lowering the dose of oxygen therapy and
document.
3. Discontinue oxygen thereby once the patient is clinically stable on the lowest dose
of oxygen and the target saturations are maintained within the desired range on
2 consecutive observations or as per Trust policy.
ADMINISTRATION BY INHALATION USING METERED DOSE INHALER
1. Sit the patient in an upright position if possible in the bed or a chair.
2. Remove mouthpiece cover from inhaler and shake inhaler well for 2-5 seconds.
3. Without a spacer device: ask patient to take a deep breath and exhale completely,
open lips, and place inhaler mouthpiece in mouth with opening toward back of
throat, closing lips tightly around it.
4. With a spacer device: insert MDI into end of the spacer device. Ask the patient to
exhale and then grasp spacer mouthpiece with teeth and lips while holding
inhaler.
5. Ask the patient to tip head back slightly, inhale slowly and deeply through the
mouth whilst depressing canister fully.
6. Instruct the patient to breathe in slowly for 2-3 seconds and hold their breath for
approximately 10 seconds, then remove MDI from mouth (if not using spacer)
before exhaling slowly through pursed lips.
7. Instruct the patient to wait 20-30 seconds between inhalations (if same medication)
or 2-5 minutes between inhalations (if different medication). Always administer
bronchodilators before steroids.
8. If steroid medication is administered, ask the patient to rinse their mouth with water
approximately 2 minutes after inhaling the dose.
GOOD PRACTICE IN SPECIMEN COLLECTION
1. Appropriate to the patient’s clinical presentation.
2. Collected at the right time.
3. Collected in a way that minimises the risk of contamination.
4. Collected in a manner that minimises the health and safety risk to all staff handling
the sample.
5. Collected using the correct technique, with the correct equipment, and in the
correct container.
6. Documented clearly, informatively, and accurately on the request forms.
7. Stored or transported appropriately.
STANDARD INFECTION CONTROL PRECAUTIONS IN RELATION TO SPECIMEN
COLLECTION
1. Hand hygiene
2. Personal Protective Equipment (PPE)
3. Safe sharps management
4. Safe handling, storage, and transportation of specimens
5. Waste management
6. Clean environment management
7. Personal and collective management of exposure to body fluids and blood.
LABELLING SPECIMENS
1. Patient’s name, date of birth, ward and/or department
2. Hospital number
3. Date and time of specimen collection
4. Type and site of specimen (specify actual anatomical site)
5. If high risk, label with “danger of infection” label
SPUTUM SAMPLING
1. Position patient upright in a chair or in a semi- or high- Fowler position, supported
as necessary with pillows.
2. If secretions are thick/tenacious or having difficulty clearing secretions: administer
nebulization therapy and/or enlist help of the physiotherapist.
3. Ask patient to take three deep breaths in through their nose, exhale through pursed
lips and then force a deep cough.
4. Ask patient to expectorate into a clean container and secure lid.
URINE SAMPLING: MIDSTREAM SPECIMEN OF URINE
1. Ask patient to wash hands with soap and water.
2. If male: ask patient to retract the foreskin and clean the skin surrounding the
urethral meatus with soap and water, 0.9% sodium chloride, or a disinfectant-free
solution.
3. If female: Ask patient to part the labia and clean the urethral meatus with soap and
water, 0.9% sodium chloride, or a disinfectant-free solution. Use a separate swab
for each wipe and wipe downwards from front to back.
4. Ask patient to begin voiding first stream of urine (approximately 15-30 mL) into a
urinal, toilet, or bedpan (and if female) whilst separating the labia.
5. Place the wide-necked sterile container into the urine stream without interrupting
the flow.
6. Ask the patient to void his/her remaining urine into the urinal, toilet, or bedpan.
7. Transfer specimen into sterile universal container.
8. Allow patient to wash hands.
SITE AND VOLUME OF INTRAMUSCULAR INJECTIONS
1. Ventrogluteal site
a. palm of the hand on the patient’s opposite greater trochanter
b. index finger then extended toward the anterior superior iliac spine to make a
“V” (gluteus medium muscle)
c. up to 2.5 mL can be safely injected
2. Deltoid site
a. visualising a triangle where the horizontal line is located 2.5-5 cms below the
acromial process and midpoint of the lateral aspect of the arm, in line with the
axilla to form the apex
b. maximum volume is 1 mL
3. Dorsogluteal site
a. upper outer quadrant (deep IM and Z-track injection)
b. up to 4 mL can be safely injected (in adults)
4. Rectus femoris site
a. middle third of the quadriceps muscle
b. 1-5 mL can be injected (1-3 mL in children)
5. Vastus lateralis site
a. up to 5 mL can be safely injected
VITAMIN B12 (HYDROXOCOBALAMIN)
1. Indications and Dose (adults)
a. prophylaxis of macrolytic anaemias associated with vitaminn B12 deficiency -
1 mg every 2-3 months
b. pernicious anaemia and other macrolytic anaemias without neurological
involvement - initially 1 mg thrice a week for 2 weeks, then 1 mg every 3 months
c. pernicious anaemia and other macrolytic anaemias with neurological
involvement - initially 1 mg once daily on alternate days until no further
improvement, then 1 mg every 2 months
d. tobacco amblyopia - initially 1 mg daily for 2 weeks, then 1 mg twice weekly
until no further improvement, then 1 mg every 1-3 months
e. Leber’s optic atrophy - initially 1 mg daily for 2 weeks, then 1 mg twice weekly
until no further improvement, then 1 mg every 1-3 months
2. Interaction - response reduced by CHLORAMPHENICOL
3. General side effects - dizziness, headache, pruritus
4. Specific (with IM injection) - chromaturia (abnormal coloration of the urine), fever,
hypersensitivity reaction, hypokalaemia (during initial treatment), injection-site
reaction, nausea, rash, thrombocytosis (too many platelets, during initial
treatment
Page 17 of 18
ANAEMIA

1. lack of RBCs —> body’s tissues and organs cannot get enough oxygen

2. lack of RBCs —> shortage of haemoglobin —> not enough oxygen delivered to
various tissues and organs

3. Symptoms of anaemia - fatigue, lethargy, dyspnoea, faintness, palpitations,

headache

PERNICIOUS ANAEMIA

1. an autoimmune process that involves gastritis, atrophy of all layers of both the
body and the fundus of the stomach and loss of normal gastric glands, mucosal
architecture, and parietal and chief cells cause achlorhydria (absence of gastric
hydrochloric acid) and lack of intrinsic factor (IF), which are required for vitamin
B12 transport across the intestinal mucosa.

2. Other causes of vitamin B12 deficiency:

a. gastric causes - gastrectomy, gastric resection, atrophic gastritis, H. pylori
infection, or congenital IF deficiency or abnormality
b. inadequate dietary intake, e.g. vegan diet (vitamin B12 present in meat and
animal protein food)
c. intestinal causes - malabsorption, ileal resection, Crohn’s disease affecting the
ileum, HIV, and other radiotherapy causing irradiation of the ileum
d. drugs - e.g. colchicine, neomycin, metformin, anticonvulsants
e. long-term use of drugs that affect gastric acid production (e.g. H2-receptor
antagonists, PPIs) can worsen deficiency because gastric acid is needed to
release vitamin B12 bound to proteins in food

3. Vitamin B12 deficiency may present with unexplained neurologic symptoms, e.g.
paraesthesia, numbness, cognitive changes, or visual disturbance.

4. Management - the BNF states that hydroxocobalamin has completely replaced

cyanocobalamin as the form of vitamin B12 of choice for therapy.

Page 18 of 18