Central Venous Catheters (CVCs)
Types of CVCs
Nursing Care
Answer
Central Venous Catheters (CVCs)
Types of CVCs:
- Tunneled and nontunneled central venous catheters.
- Implantable ports
- PICC lines
NC:
- Change dressing weekly (or per facility policy) or when soiled using aseptic technique.
- Access implantable ports with a non-coring Huber needle.
- Flush line regularly with saline and/or heparin (using 10 mL or larger syringe).
- Change injection cap (i.e., catheter hub) no more frequently than every 72 hrs or per facility policy.
- Don't take BP in the arm with a PICC line.
Card 2
Secondary Medication/IV Piggyback
Steps & Best Practices
Answer
Secondary Medication/IV Piggyback
Clamp secondary tubing and spike medication bag.
Squeeze to fill drip chamber until it is half full.
Open clamp to prime secondary tubing, then close clamp.
Hang secondary medication above primary IV solution. Primary IV may need to be lowered with plastic hook.
Scrub port on primary tubing above the IV pump and connect secondary tubing.
Program IV pump to deliver secondary infusion. Open clamp on secondary tubing and start infusion.
Label tubing with date and time.
Card 3
IV Push through Saline Lock
Steps & Best Practices
Answer
IV Push through Saline Lock
Scrub injection port with an antiseptic swab.
Attach saline flush syringe to injection port.
Aspirate and check for blood return (per facility policy).
Flush line with 3 - 5 mL of normal saline. Remove syringe.
Scrub injection port with antiseptic swab.
Attach medication syringe to injection port and inject medication at the recommended rate. Remove syringe.
Scrub injection port with antiseptic swab.
Attach saline flush syringe to injection port, and flush line with 3 - 5 mL of normal saline at same rate as medication.
Card 4
IV Push with Continuous IV Running
Steps & Best Practices
Answer
IV Push with Continuous IV Running
Assess IV fluid - medication compatibility.
Clean the injection port closest to the patient with an antiseptic swab.
Pause IV pump and close clamp or pinch tubing above the injection port.
Flush line with 3 - 5 mL of normal saline.
Inject medication at recommended rate.
Flush line with 3 - 5 mL of normal saline at the same rate as medication.
Unclamp or release tubing above injection port and restart pump.
Intramuscular Injections
Needle Size: 20 - 25 gauge, 1 - 1.5" needle.
Volume: ≤ 1mL (deltoid), ≤ 3 mL (vastus lateralis, ventrogluteal).
Administration:
- Select injection site and cleanse with an antiseptic swab.
- Stabilize the injection site with non-dominant hand.
- Insert needle at a 90° angle using dominant hand. Stabilize the syringe with the non-dominant hand.
- Inject medication at a slow and even pace.
- Remove the needle at the same angle of insertion.
- Apply bandage or gauze to site. Do not massage the site!
Z-track Method:
- Prior to administration, use the ulnar side of the non-dominant hand to laterally displace the skin by 1".
- Complete the injection process with the skin held.
- Remove the needle, then release the skin.
Subcutaneous Injections
Needle Size: 25 - 30 gauge, ⅜ - ⅝" needle.
Volume:
Administration:
- Select injection site in a fatty area (e.g., abdomen, lateral upper arms, top of thighs).
- Cleanse the site with an antiseptic swab.
- Pinch the skin to create a skin fold using non-dominant hand.
- Insert needle at a 45° angle for patients with
- After the needle is inserted, release the pinched skin and inject medication using the dominant hand.
- Remove the needle at the same angle of insertion.
- Do not massage the site.
Intradermal Injections
Needle Size: 25 - 27 gauge, ¼ - ½" needle.
Volume:
Administration:
- Select site and cleanse with an antiseptic swab.
- Spread the skin taut using the thumb and index finger of the non-dominant hand.
- Insert needle with the bevel up at a 5 - 15° angle. Advance needle until the bevel is under the skin. Do not aspirate.
- Inject medication to form a small bleb (bubble) or wheal.
- Remove the needle at the same angle of insertion.
- Do not massage the site.
Card 10
Mixing Insulin
Steps & Best Practices
Answer
Mixing Insulin
Draw up CLEAR before CLOUDY!
Inject air into the longer-acting (cloudy) insulin (e.g., NPH insulin).
Inject air into the shorter-acting (clear) insulin (e.g., regular insulin). Do not remove the needle.
Invert the vial and draw up the shorter-acting (clear) insulin. Remove the needle.
Insert the needle into the longer-acting (cloudly) insulin, invert the vial, and draw up the dose.
Gently roll vials between palms to mix them, but do not shake. Use an insulin syringe which uses units in place of milliliters.
Card 11
Glass Ampules & Multidose Vials
Steps & Best Practices for Medication Removal
Answer
Glass Ampules & Multidose Vials
Removing Medication from an Ampule:
- Tap the neck of the ampule to drop fluid down into the base.
- Wrap a small gauze pad around the neck of the ampule. Pull the top of the ampule towards your body to snap it open at the scored line.
- Withdraw fluid from the ampule using a filter needle.
- Discard the filter needle and attach an appropriate injection needle.
Do not inject air into the ampule.
Removing Medication from a Multidose Vial:
- Scrub the rubber top with an antiseptic swab.
- Inject air equal to the volume of medication to be removed into empty space above medication level.
- Invert the vial, keeping the tip of the needle below the fluid level, and draw up the medication.
Card 12
NG/PEG Tube Route
Steps & Best Practices
Answer
NG/PEG Tube Medication Administration
Verify tube placement and position patient into a semi-Fowler's position or higher.
Use liquid forms of medications when possible. Crush and dissolve tablets in 15 - 30 mL of water.
Flush tube with 30 mL of water.
Administer medications per facility policy:
- Gravity: Remove the plunger from a 60 mL syringe and connect it to the tube. Pour prepared medications into the open end of the syringe.
- Push: Draw up dissolved medication with syringe and connect to the tube. Push slowly to deliver.
Flush tube with 30 mL of water.
When administering more than one medication, administer each medication separately and flush with water between each medication.
Card 13
Transdermal Route
Steps & Best Practices
Answer
Transdermal Medication Administration
Don gloves when handling transdermal medications.
Remove prior dose (if applicable).
Apply to a clean, dry, intact, and hairless area. For patches, press firmly to secure.
Label with date, time, and initials.
Apply patches to alternating approved sites to prevent skin irritation.
Inhalation Medication Administration
MDI:
- Shake the inhaler and attach a spacer.
- Place the mouthpiece between lips and inhale slowly/deeply
(> 3 sec).
- Hold breath for 10 seconds.
- Remove inhaler from mouth and slowly exhale.
DPI:
- Do not shake device or use a spacer.
- Place device between lips and sharply inhale to activate.
- Hold breath for 10 seconds.
- Remove inhaler from mouth and slowly exhale.
Card 15
Nasal Route
Steps & Best Practices
Answer
Nasal Medication Administration
Ask the patient to blow their nose.
Position patient with their head tilted back.
Insert the tip of the applicator into one nostril and occlude the opposite nostril.
Compress the bottle to release a spray as the patient breathes in through their nose.
Repeat in the other nostril as ordered.
Advise the patient to tilt their head back for a few minutes and avoid blowing their nose after administration.
Card 16
Otic Route
Steps & Best Practices
Answer
Otic Medication Administration
Position patient on their unaffected side.
Pull the pinna up and back for adults, or down and back for children
Hold dropper above ear canal without touching ear.
Instill drops by allowing them to hit the side of the ear canal and run into the ear.
Let go of the pinna and press gently on the tragus several times. If ordered, place a cotton ball in the ear canal.
Have the patient remain on their side for 5 minutes.
Card 17
Optic Route
Steps & Best Practices
Answer
Optic Medication Administration
Don clean gloves and offer patient a tissue.
Have the patient tilt their head back and look up.
With the nondominant hand, pull the lower lid down gently to expose the conjunctival sac.
Drop medication in the conjunctival sac, without touching the eye with the dropper.
Apply gentle pressure to the inner canthus for ~1 minute to prevent systemic absorption.
Wait 5 minutes between administration of different optic medications.
Card 18
Sublingual/Buccal Route
Best Practices
Answer
Sublingual/Buccal Medication Administration
Wear clean gloves if placing medications in the patient's mouth.
Instruct patient not to swallow or chew the medication.
Educate patient not to eat or drink until the medication has completely dissolved.
Place sublingual medications under the tongue.
Place buccal medications between the gum and cheek.
Card 19
Oral Route
Best Practices
Answer
Oral Medication Administration
Assess patient for contraindications, including: decreased level of consciousness, absent gag reflex, dysphagia, vomiting, NG suctioning.
Place the patient in an upright position (e.g., high-Fowler's position).
If needed, mix medication with a small amount of food.
Do not crush enteric-coated or extended-release medications.
For liquid medications, place the measuring device on a flat surface at eye level and measure at the meniscus (i.e., the lowest point).
Card 20
Safe Medication Administration
Best Practices
Answer
Safe Medication Administration
Review and verify orders.
Identify patient using 2 approved identifiers.
Assess for allergies.
Educate the patient on the medication's purpose and potential side effects.
Follow the rights of medication administration.
Document after completing medication administration.
Immediately deploy needle safety devices after use.
Dispose of all equipment per facility policy (e.g., sharps box, biohazard container).
Evaluate the patient's response to medication(s).
Card 21
Blood Transfusion
Best Practices
Answer
Blood Transfusion
If the transfusion is not initiated within 30 minutes, return blood bag to the blood bank.
Set the IV pump at a slower rate for the first 15 minutes. Then, increase the rate if there are no signs of a transfusion reaction.
If signs of a transfusion reaction are observed, stop the transfusion immediately and administer normal saline through a separate line.
After obtaining blood products from the blood bank, transfusion must be completed within 4 hours.
Card 22
Blood Transfusion
Steps (2 of 2)
Answer
Blood Transfusion (2 of 2)
Obtain baseline vital signs.
Obtain blood product from the blood bank. Visually inspect the bag for appropriate color and consistency.
Confirm patient ID and blood bag label (including blood type, blood unit #, and expiration date/time) with a second RN.
Insert second tubing spike into blood bag and hang on IV pole.
Clamp saline tubing and unclamp blood tubing.
Prime the tubing with the blood product using the IV pump. The transfusion officially begins when the blood reaches the patient.
Stay with the patient for the first 15 minutes to monitor for transfusion reactions.
Reassess vital signs 15 minutes after transfusion begins and upon completion of the transfusion (or per facility policy).
Card 23
Blood Transfusion
Steps (1 of 2)
Answer
Blood Transfusion (1 of 2)
Assess patient's history of transfusion reactions and confirm consent has been obtained.
Ensure ≥ 20 gauge IV catheter (18 gauge preferable) is patent.
Prime blood administration set (e.g., Y-type tubing) with normal saline ONLY.
- Close both clamps on Y-type tubing.
- Insert one tubing spike into saline bag and hang on IV pole.
- Squeeze drip chamber on administration set until normal saline fully covers the filter inside the chamber.
- Open clamp on saline tubing and prime the line.
If using secondary blood tubing instead of Y-type tubing, follow facility policy for priming.
Card 24
Central Venous Catheter Removal
Steps & Best Practices
Answer
CVC Removal
Position patient supine and don clean gloves.
Remove dressing while stabilizing the catheter with one hand.
Have patient take a deep breath and hold it. If they can, instruct them to bear down.
Withdraw catheter slowly and gently, keeping it parallel to the skin.
Apply pressure to the site with sterile gauze for 1 - 5 minutes, then apply a sterile occlusive dressing (e.g., petroleum gauze).
Assess that the catheter length matches the documented length and is intact.
Have patient remain supine for 30 minutes following procedure.
Card 25
Central Venous Catheter Dressing Change
Steps & Best Practices
Answer
CVC Dressing Change
Don mask and clean gloves. Place mask on patient, and turn patient's head away from insertion site.
Remove old dressing without pulling on catheter.
Assess site for signs of infection.
Set up sterile field. Don sterile gloves.
Clean area around site with chlorhexidine solution.
Apply new stabilization and antimicrobial devices.
Apply new sterile dressing and label it with initials, date, and time.
Card 26
Drawing Blood from a Central Venous Catheter (CVC)
Steps & Best Practices
Answer
Drawing Blood from a CVC
Remove disinfectant cap and scrub catheter hub.
Connect 10 mL saline syringe and flush line.
Draw off waste amount (per facility policy) and discard.
Connect new syringe or blood collection tube. Collect blood sample(s).
Flush line with normal saline (amount per facility policy).
Place new disinfectant cap over catheter hub.
Card 27
Peripheral IV Removal
Steps & Best Practices
Answer
Peripheral IV Removal
If applicable, turn off pump, clamp and disconnect tubing.
Stabilize the cannula while removing the dressing.
Place sterile gauze over the insertion site and steadily withdraw catheter.
Apply pressure for 30 seconds (or 5 -10 minutes if patient takes anticoagulants).
Visually inspect the catheter. If it is not intact, immediately report this finding to the provider.
Secure gauze with tape.
Card 28
IV Fluid/Bolus Administration
Steps & Best Practices
Answer
IV Fluid/Bolus Administration
Close the clamp on the primary tubing.
Hold solution bag upside-down and remove protective cover from the IV solution port.
Remove protective cover from IV tubing spike.
While maintaining sterility, gently push and twist the spike into the port. Hang bag on IV pole.
Gently squeeze the drip chamber until it is half full.
Prime the line by holding the distal end of the tubing over the sink, and unclamp the tubing until fluid reaches the end.
Clamp the tubing and ensure there are no air bubbles in the line.
Scrub the patient's IV port with an antiseptic wipe and connect tubing.
Set rate using pump or gravity according to order. Unclamp the tubing and start infusion.
Label tubing and IV bag with date, time, and initials.
Card 29
Peripheral IV Care
Best Practices
Answer
Peripheral IV Care
Maintain IV patency by flushing with normal saline every 8 - 12 hours if the patient is not receiving a continuous IV infusion.
Change primary tubing every 72 - 96 hours, secondary tubing every 24 hours, and blood product tubing every 4 hours (or between products).
Wipe the port with an antiseptic wipe for 15 seconds and allow it to dry before connecting a line or syringe.
Never give medications through a line receiving blood products.
Assess site for patency, phlebitis, infiltration.
All unused ports should be capped with a disinfecting cap (per hospital policy).
Card 30
IV Start/Venipuncture
Steps & Best Practices (2 of 2)
Answer
IV Start/Venipuncture (2 of 2)
Reapply tourniquet. Hold skin taut 1 - 2" below entry site with non-dominant hand. Do not touch the prepped site
Insert needle at 30 - 45° angle, bevel up.
When flashback is observed, lower the angle and advance the needle ~ 1 mm further. Then, push the catheter off the needle and advance until the hub is at the venipuncture site.
Deploy needle safety device.
With non-dominant hand, apply pressure above insertion site. Release tourniquet and attach primed tubing.
Flush site to test for patency. If patent, secure site with transparent dressing indicating date, time, initials, and gauge.
A new sterile needle is required for each insertion attempt.
Card 31
IV Start/Venipuncture
Steps & Best Practices (1 of 2)
Answer
IV Start/Venipuncture (1 of 2)
To select a site, place the patient's arm in a dependent position and apply a tourniquet 2 - 4" above the potential insertion site.
- Prioritize distal veins on non-dominant arm.
- Avoid hard/sclerosed veins, areas of high flexion (e.g., antecubital fossa), and the ventral side of the wrist.
- Avoid using the same side as mastectomy or AV fistula.
Remove tourniquet, perform hand hygiene, and don clean gloves.
Clean site with antiseptic wipe, using a circular motion from the center outward.
Prime extension tubing, remove cap, and place the end back into sterile packaging.
Card 32
Defibrillation
Steps & Best Practices
Answer
Defibrillation
As equipment is being prepared, continue CPR.
Attach pads according to defibrillator instructions.
Set the energy level to 120 joules, or according to manufacturer recommendation.
If a shock is indicated, ensure care providers cease CPR and stop touching the patient.
Immediately resume compressions after shock is delivered.
Defibrillation is only indicated for ventricular fibrillation or ventricular tachycardia.
Card 33
12-Lead EKG
Electrode Placement Illustration
Answer
12-Lead EKG - Electrode Placement
Card 34
12-Lead EKG
Electrode Placement
Answer
12-Lead EKG - Electrode Placement
Chest Electrodes (6):
- V1 = Fourth intercostal space, right sternal border
- V2 = Fourth intercostal space, left sternal border
- V3= Midway between V2 and V4
- V4 = Fifth intercostal space, left midclavicular line
- V5 = Level with V4, left anterior axillary line
- V6 = Level with V5, left midaxillary line
Limb Electrodes (4):
- RA = Right arm
- LA = Left arm
- RL = Right leg
- LL = Left Leg
The term "leads" refers to how many angles are used to examine the heart's activity. There are 12 leads, but 10 electrodes.
Card 35
Tracheostomy Care
Steps for Cleaning the Tracheostomy Site
Answer
Cleaning the Tracheostomy Site
Perform hand hygiene and don clean gloves.
Prepare sterile field and pour sterile saline. Don sterile gloves.
Clean around stoma under faceplate using cotton-tipped applicators and sterile saline. Clean from stoma site outward, using each applicator only once. Dry gently.
Place new dressing under faceplate. Do not cut gauze; use pre-split gauze only.
Leave old ties in place until new ties are secured. Ensure one finger fits between the neck and the tie.
Replace oxygen.
Card 36
Tracheostomy Care
Steps for Cleaning a Reusable Inner Cannula
Answer
Cleaning a Reusable Inner Cannula
Ensure patient is in semi- or high-Fowler's position.
Don clean gloves, prepare sterile field and tray, and pour sterile saline.
Touching only the faceplate, remove inner cannula and drop it into the sterile solution.
Remove clean gloves and don sterile gloves.
Clean inner cannula with a sterile pipe cleaner.
Dry inner cannula with a new sterile pipe cleaner and reinsert, ensuring it is secure.
Card 37
Tracheal Suctioning
Steps & Best Practices (2 of 2)
Answer
Tracheal Suctioning (2 of 2)
Insert catheter into tracheal opening using dominant hand quickly but gently. Stop when resistance is felt or coughing occurs. Do not apply suction during insertion.
Intermittently apply suction while rotating the catheter during withdrawal. Limit each pass to
Reoxygenate the patient for at least 30 seconds, and encourage coughing and deep breathing.
Suction sterile saline to clear tubing between passes. A maximum of 3 passes may be performed.
Don't forget: Offer oral care after suctioning.
Card 38
Tracheal Suctioning
Steps & Best Practices (1 of 2)
Answer
Tracheal Suctioning (1 of 2)
Hyperoxygenate the patient.
Set wall suction between 80 - 210 mmHg.
Open/prepare suction kit, sterile field, and sterile saline. Don sterile gloves.
Pick up the sterile suction catheter with the (sterile) dominant hand and connect it to suction with the (now clean) nondominant hand.
Occlude the hole on suction catheter to check suction function with nondominant hand.
Inserting Adjunct Airways
Oropharyngeal Airway (OPA):
- Select OPA which fits from the corner of the mouth to the mandibular angle.
- Insert into the mouth with the tip of device pointing towards the roof of the mouth.
- Rotate 180° while inserting to push tongue forward.
Nasopharyngeal Airway (NPA):
- Select NPA which fits from the corner of the nose to the earlobe.
- Generously lubricate the NPA.
- Insert into nare with tip pointed down, aiming straight back.
Respiratory Specimen Collection
Oropharyngeal: Swab posterior pharynx and both tonsils avoiding tongue, teeth, and gums.
Nasopharyngeal: Tilt patient's head back. Insert swab parallel to palate, stop when resistance is met. Gently rotate in nare for a few seconds to absorb secretions.
Sputum: Discuss difference between sputum and saliva with patient. Instruct patient to rinse mouth with water, then cough deeply and expectorate into a sterile collection cup. Best collected in the morning due to accumulation of secretions.
Label specimens with date, time, initials, and site of collection.
Card 41
Incentive Spirometer
Patient Teaching
Answer
Incentive Spirometer - Patient Teaching
Sit up straight (i.e., high-Fowler's).
Exhale completely.
Place lips around mouthpiece and attempt to reach the predetermined volume by inhaling slowly and deeply for 2 - 6 seconds.
INcentive spirometer = breathe IN.
Teach patient proper technique before surgery and determine baseline. Reinforce teaching after surgery. Advise patient to use ~ 10 times/hr while awake.
Card 42
Changing an Ostomy Appliance
Steps & Best Practices
Answer
Changing an Ostomy Appliance
Gently remove current ostomy appliance.
Cleanse skin with warm, wet washcloth and allow skin to dry completely.
Measure stoma using the measuring guide. Find the circle size on the card that fits closest to the stoma without touching it (≤ ⅛" bigger than the stoma).
Trace the chosen circle size onto the back of the wafer and cut out using curved scissors.
Utilize a skin preparation product to improve adhesion and prevent skin breakdown.
Remove backing from wafer and apply over stoma. Hold in place for a few minutes.
Card 43
Emptying an Ostomy Bag
Steps & Best Practices
Answer
Emptying an Ostomy Bag
Remove the appliance/pouch clamp, and cuff the end of the pouch.
Empty contents into a bedpan, toilet, or measuring device. It may be necessary to milk the bag to remove contents.
Optional: Rinse appliance/pouch with tepid water and dry the lower section.
Uncuff the appliance/pouch and close with clamp.
Empty when bag is 1/3- 1/2 full.
Card 44
Fecal Occult Blood Test (FOBT)
Steps & Best Practices
Answer
Fecal Occult Blood Test (FOBT)
Collect stool in a clean container. Stool mixed with urine cannot be used.
Obtain sample from one area of the stool and apply on testing card slot A.
Obtain sample from a separate area of the stool and apply on testing card slot B.
Apply reagent to card.
If blood is present, the card turns blue.
Card 45
Large Volume Cleansing Enema Administration
Steps & Best Practices
Answer
Large Volume Cleansing Enema Administration
Have bedside commode, bedpan, or bathroom ready for use.
Warm enema solution to room temperature and prime tubing.
With tubing clamped, elevate solution ≤ 18" above patient.
Place patient in modified left lateral recumbent position (i.e., Sims').
Lubricate enema tip and insert 3- 4" (7.5 - 10 cm) into the anus, angling the tip towards the umbilicus.
Administer enema slowly over 5 - 10 minutes.
Lower container of solution (or clamp tubing) for cramping.
After administration, encourage patient to remain on their side, retain contents, and resist toileting for ~ 10 minutes.
Assist patient to bathroom or bedside commode.
Card 46
Indwelling Catheter Removal
Steps & Best Practices
Answer
Indwelling Catheter Removal
Place waterproof pad under patient.
Empty urine from bag and measure.
Detach tubing from the securement device.
Attach an empty syringe to the balloon port and aspirate the same amount of fluid that was originally instilled.
Withdraw catheter steadily.
Provide perineal care.
Remove as soon as appropriate.
Card 47
Indwelling Urinary Catheter Care
Best Practices
Answer
Indwelling Urinary Catheter Care
Hang the drainage bag on the bed frame below the level of the patient's bladder, but do not place on floor.
To avoid obstruction, frequently check tubing for kinks and dependent loops. Ensure patient is not lying on tubing.
Clean around the meatus daily and after each bowel movement. Clean from the meatus outward.
If leakage or disconnection occurs, replace the catheter and collection system.
Empty contents of bag into a graduated container to accurately measure urine output.
Card 48
Closed Continuous Catheter Irrigation
Steps & Best Practices
Answer
Closed Continuous Catheter Irrigation
Clearly label bag of irrigation solution with "bladder irrigant" and date/time. Hang the bag 2.5 - 3 feet above patient.
Clamp tubing, spike solution, and prime tubing.
Clean irrigation port on urinary catheter, then connect irrigation tubing.
Set drip or pump to ordered irrigation rate then unclamp tubing.
Monitor output and drainage bag (it will need to be emptied frequently).
Clamp tubing and change bag (as ordered) before drip chamber is empty.
Indwelling Catheters - Sterile Urine Collection
If ordered, collect urine specimen from drainage bag immediately after insertion. If it is not a new insertion do NOT use drainage bag.
Clamp tubing below the specimen collection port for 10 - 15 minutes.
Scrub specimen port with antiseptic swab.
Access specimen port using a 10 mL syringe and aspirate at least 3 mL of urine.
Deposit urine into sterile specimen container.
Close and label specimen cup with initials, date, time, and patient info.
Unclamp tubing.
Card 50
Indwelling Urinary Cather Insertion - Males
Steps & Best Practices (2 of 2)
Answer
Indwelling Urinary Cather Insertion - Males
Optional: Insert lubricant syringe into the urethra and instill 10 mL of lubricant.
Ask patient to bear down. Insert catheter with dominant hand to the Y port.
Hold catheter with nondominant hand and inflate catheter balloon with dominant hand.
Pull gently on catheter until resistance is felt.
Return the foreskin to its normal position for an uncircumcised patient.
Secure catheter tubing to patient's thigh and place drainage bag below level of bladder.
Card 51
Indwelling Urinary Cather Insertion - Males
Steps & Best Practices (1 of 2)
Answer
Indwelling Urinary Cather Insertion - Males
Position patient supine and clean perineal area.
Set up sterile field, don sterile gloves, place fenestrated drape over patient's penis.
Attach prefilled saline syringe to balloon inflation port, generously lubricate catheter tip.
Hold penis at a 90° angle with non-dominant hand. If uncircumcised, retract the foreskin.
With dominant hand, clean the penis in concentric circles from the meatus down the glans of the penis using sterile cleansing swabs. Repeat two more times, using a new swab each time.
Card 52
Indwelling Urinary Cather Insertion - Females
Steps & Best Practices (2 of 2)
Answer
Indwelling Urinary Cather Insertion - Females
Instruct patient to bear down.
Insert lubricated catheter into urethra and advance until urine is seen in tubing. Then advance catheter an additional 2 - 3".
Hold catheter with nondominant hand and inflate catheter balloon with dominant hand.
Pull gently on catheter until resistance is felt.
Secure catheter tubing to patient's thigh and place drainage bag below level of bladder.
Card 53
Indwelling Urinary Cather Insertion - Females
Steps & Best Practices (1 of 2)
Answer
Indwelling Urinary Cather Insertion - Females
Position patient in dorsal recumbent position and clean perineal area.
Set up sterile field, don sterile gloves, and position fenestrated drape over patient's vulva.
Attach prefilled saline syringe to balloon inflation port, and generously lubricate catheter tip.
Use non-dominant hand to separate labia and expose urethral meatus.
With dominant hand, clean one labial fold, then the other, then directly over the meatus with sterile cleansing swabs. Clean from top to bottom, using a new swab for each stroke.
Card 54
Straight Catheter Insertion - Males
Steps & Best Practices
Answer
Straight Catheter Insertion - Males
Position patient supine and clean perineum.
Set up sterile field and don sterile gloves.
Generously lubricate catheter tip. Position a collection device to collect urine flow when catheter is inserted.
Hold penis at a 90° angle with non-dominant hand. If uncircumcised, retract the foreskin.
With dominant hand, clean the penis in concentric circles from the meatus down the glans of the penis using sterile cleansing swabs. Repeat two more times, using a new swab each time.
Instruct patient to bear down. Insert catheter and allow urine to drain into collection device.
After urine flow stops, remove catheter. Assess and measure output.
Card 55
Straight Catheter Insertion - Females
Steps & Best Practices
Answer
Straight Catheter Insertion - Females
Position patient in dorsal recumbent position and clean perineum.
Set up sterile field and don sterile gloves.
Generously lubricate catheter tip. Position a collection device to collect urine flow when catheter is inserted.
Use non-dominant hand to separate labia and expose urethral meatus.
With dominant hand, clean one labial fold, then the other, then directly over the meatus with sterile cleansing swabs. Clean from top to bottom, using a new swab for each stroke.
Instruct patient to bear down. Insert catheter and allow urine to drain into collection device.
After urine flow stops, remove catheter. Assess and measure output.
Card 56
Bladder Scanner
Steps for Scanning a Bladder
Answer
Bladder Scanner
Encourage patient to void if possible in order to assess for postvoid residual amount.
Turn on scanner, select button indicating if the patient has a uterus.
Apply ultrasound gel to scanner head or patient's abdomen. Place scanner 1" above symphysis pubis. Point scanner slightly down towards the bladder.
Press the scan button. Adjust the probe location as needed to center the bladder image on the crosshairs shown on the scanner screen.
Press "done" when satisfied with results and print.
Card 57
Condom Catheters
Steps for Applying Condom Catheters
Answer
Condom Catheters
Provide perineal care. Clip hair at base of penis if needed.
Select appropriate size product.
Stabilize the penis by holding it with the nondominant hand. Apply condom sheath with the dominant hand by rolling it onto the penis.
Allow 1 - 2" of space between the tip of penis and the end of the condom sheath.
If device is self-adherent, apply gentle pressure for 10 - 15 seconds. If using tape, apply in a spiral fashion ensuring it is snug but not constricting.
Attach to drainage bag.
Replace daily.
Card 58
Midstream Clean Catch
Steps & Best Practices
Answer
Midstream Clean Catch
Provide instructions or assist with cleansing using designated wipes.
Male: If uncircumcised, retract foreskin. Clean tip of penis starting at urethral meatus in concentric circles.
Female: Separate the labia and wipe front to back. Continue to hold labia apart during urination.
Urinate into toilet initially, then pause urination.
Urinate ~15 - 30 mL into sterile container.
Withdraw container from stream and finish urinating into toilet.
Close and label container.
Card 59
Enteral (Tube) Feedings
Open System/Gravity Feed:
- Administration Steps
Answer
Open System/Gravity Feed
Confirm orders, delivery, and product.
Remove the plunger from a 60 mL syringe.
Clamp feeding tube and insert syringe into port.
Hold syringe above the level of patient's stomach.
Unclamp feeding tube and flush with 30 mL of water.
Pour formula slowly into syringe allowing gravity to control speed. If cramping occurs, lower syringe to decrease rate.
After feeding, flush with 30 mL of water.
Clamp feeding tube and disconnect syringe.
Closed System/Feeding Pump
Confirm orders, delivery, and product.
Label feeding bag with formula name, date, and time. Pour formula into feeding bag.
Hang bag on pole, loop tubing into the pump, and prime the line.
Flush the patient's feeding tube with 30 mL of water, then connect tubing.
Verify pump rate, start feed, and ensure all clamps are open.
Card 61
Enteral (Tube) Feedings
Best Practices
Answer
Enteral Feedings - Best Practices
Before feeding: Perform abdominal assessment, confirm presence of bowel sounds, and confirm tube placement.
Aspirate gastric contents with syringe and measure gastric residual volume (GRV). Follow facility policy re: holding feeding for large GRV (e.g., > 500 mL) and returning residuals to the stomach.
Keep HOB 30 - 45° to ↓ aspiration risk during feeding and for ≥ 1 hour after feeding.
Card 62
NG Tube Removal
Steps & Best Practices
Answer
NG Tube Removal
Cover patient's chest with towel.
Optional: Confirm tube placement and flush with water or air prior to removal.
Remove securement device.
Instruct patient to take a deep breath and hold it.
Remove tubing quickly and smoothly.
Offer patient oral care and tissue to blow nose.
Card 63
NG Tube Care
Best Practices
Answer
NG Tube Care: Best Practices
Confirm placement:
- Confirm INITIAL placement with X-ray!
- Measure length of exposed NG tube and confirm with documented length.
- Verify pH of aspirated contents. Normal pH of gastric contents is
Do not instill air into tube to check placement!
Do not pull on tube or insert anything into air vent.
Keep HOB elevated.
Assess nares daily for mucosal breakdown.
Card 64
NG Tube Insertion
NG Tube Insertion
Answer
NG Tube Insertion
Elevate HOB, cover patient's chest with towel, provide basin and tissues.
Estimate length of tube needed by measuring from the tip of the nose, to the earlobe, to the xiphoid process. Mark position on tubing with permanent marker or tape.
Lubricate tip of tube and insert into the nostril towards the back of the patient's throat.
Encourage patient to sip water through a straw or swallow.
Advance firmly but do not push past extreme resistance.
Once inserted to predetermined length, secure tube to nose.
Mark the tubing where it exits nare and document that measurement.
Card 65
Capillary Blood Glucose Sample
Steps for Obtaining a Blood Glucose Sample
Answer
Capillary Blood Glucose Sample
Clean site with antiseptic swab. Allow skin to dry completely.
Lower patient's hand to encourage bleeding.
Using a lancet, pierce the skin at the lateral, distal end of the fingertip (not the pad of finger).
Wipe away the first drop of blood with gauze.
Touch test strip to drop of blood without smearing it.
Apply pressure to puncture site with dry gauze.
Dispose of test strip and lancet appropriately (e.g., sharps box).
Card 66
Site Care of a Closed Drain
Steps & Best Practices
Answer
Site Care of a Closed Drain
Remove old drain gauze.
Clean site around drain using a new cotton swab for each swipe.
Assess for signs/symptoms of infection (e.g., redness, purulent or malodorous discharge, swelling).
Apply new drain gauze and secure with tape.
Change dressing daily (or per orders).
Card 67
Emptying a Closed Drain (JP & Hemovac Drain)
Steps & Best Practices
Answer
Emptying a Closed Drain
Open cap directed away from self to prevent fluid splashing.
Pour contents into measuring canister.
Note amount, consistency, odor, and color.
Fully compress container and replace cap.
Discard fluid in toilet.
Empty drain before half full. Secure device to clothing to prevent pulling at insertion site.
Card 68
Removing Sutures/Staples
Steps & Best Practices
Answer
Removing Sutures/Staples
Clean incision with wound cleanser or normal saline before removal of sutures/staples.
Remove sutures or staples:
Sutures: Grasp the knot of the suture with forceps and gently lift. Cut one side of the suture below the knot (close to the skin). Pull the cut suture through the skin.
Staples: Place lower jaw of staple remover under the center of the staple and squeeze the handles together.
Count and chart the number of sutures/staples removed.
Suture/staple removal requires a provider order. Remove alternate sutures/staples to assess for wound dehiscence.
Card 69
Wound Culture
Steps & Best Practices
Answer
Wound Culture
Remove dressing and irrigate wound with normal saline (do not use wound cleanser).
Dry the wound bed with sterile gauze.
Swab a 1 cm area of viable tissue in the wound bed for ~ 5 seconds with enough force to produce exudate.
Redress wound per orders.
Label culture tubing with site of culture.
Obtain before beginning antibiotic therapy. Do NOT swab necrotic tissue, and do NOT touch the skin surface with the swab.
Card 70
Wound Irrigation
Steps & Best Practices
Answer
Wound Irrigation
Don gown, gloves, and eye protection.
Place waterproof pad and basin under site.
Position the patient so solution will run from the wound bed into the basin.
Hold syringe about 1" above site.
Apply direct stream of normal saline or prescribed solution at a steady, consistent pressure.
Repeat until the runoff is clear.
Dry the site with sterile gauze.
Remove PPE and perform hand hygiene.
Redress wound per orders.
Card 71
Sterile Wound Dressing Change
Steps & Best Practices
Answer
Sterile Wound Dressing Change
Perform hand hygiene and remove soiled dressing using clean gloves.
Note wound appearance/drainage. Discard soiled dressing and gloves.
Perform hand hygiene and set up sterile field. Don sterile gloves.
Clean the wound. Moisten gauze with sterile saline or wound cleanser. Gently clean from top to bottom and/or from the center of the wound moving outward. Use a new piece of gauze for each stroke.
Pat the wound bed and surrounding area dry with sterile gauze.
Apply prescribed topical medications and secure a dry, sterile dressing over wound.
Label dressing with date, time, initials.
Clean (vs. sterile) gloves may be appropriate for cleaning some chronic wounds.
Card 72
Standing Transfer
Steps for Bed to Chair/Wheelchair Transfer
Answer
Bed to Chair/Wheelchair Transfer
Position the chair at 45° angle, ensuring brakes are locked.
Raise HOB and assist patient to sit on the side of the bed with feet on the floor.
Brace the patient's weaker leg with your leg to facilitate standing.
Assist patient to stand, utilizing gait belt if needed.
If patient is too weak or unsteady, immediately return them to a sitting position.
Pivot and aid patient in turning until the back of their legs touch the chair.
Ask patient to lower themself using arm rests.
Use for cooperative patients who can bear weight, stand, and pivot.
Card 73
Lateral Transfer
Steps & Best Practices
Answer
Lateral Transfer
Position height of destination surface ½" lower than starting surface.
Place HOB flat and lower side rails.
If using a slider board, position halfway under the patient. Otherwise, utilize a draw sheet.
With other caregivers, move patient together using a count of three.
Remove slider board if used.
Card 74
Moving Patient Up In Bed
Steps & Best Practices
Answer
Moving Patient Up In Bed
Place HOB flat (or in Trendelenburg position) and move pillow to be against headboard.
Stand at patient's hips and collect the draw sheet close to the patient's side.
Ask patient to lift their head and elbows off the bed (i.e., give themself a hug).
On the count of three slide the patient. If the patient is able, have them flex their knees and push.
Replace pillow and position patient to their preference.
Always have someone assist you!
Card 75
Controlled Patient Fall
Steps & Best Practices
Answer
Controlled Patient Fall
Stand behind the patient.
Hold patient's hips or gait belt.
Bend one knee and position it between the patient's legs.
Slowly guide the patient down using your leg to support them.
Protect their head from hitting the floor.
Card 76
Safe Patient Movement
Best Practices
Answer
Safe Patient Movement
Assess patient status and ability to assist.
Determine which assistive devices are needed and how many personnel should be present.
Follow proper body mechanics:
- Keep feet shoulder-width apart for a wide base of support.
- Bend with knees, keep back straight, and tighten abdominal muscles.
- Do not twist at the spine!
- Keep weight close to body.
Card 77
Oral Care & Denture Care
Steps & Best Practices
Answer
Oral Care & Denture Care
Oral Care:
- For an unconscious patient, raise HOB ≥ 45° and turn head to the side to prevent aspiration.
- Place basin under patient's chin, or provide cup for rinsing and spitting if patient is alert.
- Brush all surfaces of the teeth.
Do not place your fingers in the patient's mouth.
Denture Care:
- Place towel in sink to prevent damage if dentures fall.
- Brush dentures with toothbrush and toothpaste or denture cleaner.
- Rinse and store in labeled container with denture solution or water.
Card 78
Bed Bath
Steps & Best Practices
Answer
Bed Bath
Offer elimination first.
Fill basin with warm water.
Remove patient gown using snaps. Do not disconnect IV.
Cover areas not currently being washed.
Create mitt with washcloth.
Wash face first without soap.
Work down the body washing, rinsing, and drying each body part.
Clean the perineum last.
Female: Spread labia and clean front to back using new portion of washcloth with each stroke.
Male: Begin at tip of penis, retracting foreskin if necessary. Wipe in circular motions at the tip, then in downward strokes.
Card 79
Occupied Bed Making
Steps & Best Practices
Answer
Occupied Bed Making
Ensure wheels are locked, lower HOB, and remove all pillows.
Assist patient in rolling to one side.
Untuck and roll soiled sheets lengthwise, tucking under patient.
Place clean fitted sheet on open side, tucking under soiled sheets.
Assist patient in rolling over gathered linen to clean side of bed.
Remove soiled linen and place directly in soiled linen bin.
Pull clean linen to cover mattress.
Assist patient in rolling to neutral position.
Complete bed making with top sheet and blanket.
Do not shake out linen or hold soiled linen against self.
Card 80
Vital Signs - Orthostatics
Steps for Assessing Orthostatic Hypotension
Answer
Vital Signs - Orthostatics
Have the patient lie supine for at least 5 minutes, then take their BP and pulse.
Sit patient up, wait 2 - 3 min, then take their BP and pulse.
Have the patient stand up, wait 2 min, then take their BP and pulse.
Evaluate changes indicating orthostatic/postural hypotension:
- A total drop in SBP of ≥ 20 mmHg when changing positions.
AND/OR
A total drop in DBP of ≥ 10 mmHg when changing positions.
Monitor for dizziness, weakness, and pulse changes during assessment.
Card 81
Vital Signs - Blood Pressure
Steps for Obtaining a Blood Pressure
Answer
Vital Signs - Blood Pressure
Choose appropriate arm to take BP. Avoid using arm with running IV infusion, PICC line, AV fistula, or on same side as a mastectomy.
Position patient's arm relaxed and supported at heart level, with legs uncrossed.
Choose appropriate cuff size and apply cuff snugly 1" above brachial artery.
Palpate the radial pulse while inflating the cuff until the pulse disappears.
Continue inflating the cuff an additional 30 mmHg.
Place the stethoscope over the brachial artery while slowly and steadily releasing air from the cuff.
Note when you hear the first sound (SBP) and when the sound disappears (DBP).
Card 82
Vital Signs - Respirations
Assessment
Answer
Vital Signs - Respirations
Assess: Rate, depth (e.g., deep, shallow), pattern (e.g., regular, irregular).
- While your fingers are still in place after taking the patient's pulse, observe the rise and fall of the patient's chest without mentioning that you are counting respirations.
For a regular pattern, count for 30 seconds and multiply by 2. For an irregular pattern, count for a full minute.
Card 83
Vital Signs - Pulse
Assessment of Radial & Apical Pulse
Answer
Vital Signs - Pulse
Assess: Rate, rhythm (e.g., regular or irregular), equality (e.g., right vs. left side), and strength (e.g., 0 - 4).
- Radial: Take on the wrist proximal to the thumb, using the pads of your first three fingers.
- Apical: Listen with stethoscope at the fifth intercostal space at the left midclavicular line.
For a regular rhythm, count for 30 seconds and multiply by 2. If the pulse is irregular or if the patient is taking cardiac medications, count for a full minute.
Vital Signs - Temperature
Oral: Place probe beneath patient's tongue in the posterior sublingual pocket. Ask the patient to close lips around the probe.
Temporal: Slide probe from the center of the forehead to the hairline behind the ear.
Tympanic: For adults pull the pinna up and back,
Axillary: Place probe in center of the axilla. Have patient bring arm down close to the body.
Rectal: Place patient in modified left lateral recumbent position (i.e., Sims'), use lubrication and insert ~1" angled towards the umbilicus.
Card 85
Adding Items to a Sterile Field
Best Practices
Answer
Adding Items to a Sterile Field
Add items by opening package and dropping item from 6" above field.
If using sterile solution, open cap and place it so the inside of the cap is facing up on a non-sterile surface.
- Hold the bottle with your palm covering the label.
- Pour at a height that does not result in splashing (e.g., 4 - 6").
A sterile surface that becomes wet is no longer sterile.
Card 86
Preparing a Sterile Field
Steps & Best Practices
Answer
Preparing a Sterile Field
Remove outside wrapper and discard.
Position package so top flap will open away from your body.
Open top flap away from you first.
Next, open the right flap with your right hand and the left flap with your left hand (so you do not reach over the sterile field).
Open the flap towards your body last.
When opening the package, pinch the outside of the flaps to avoid touching the inner sterile surface.
Card 87
Sterile Gloving
Steps for Applying Sterile Gloves
Answer
Sterile Gloving
Remove jewelry and perform hand hygiene.
Open outer packaging and discard.
Open inner wrapper without touching gloves or inside of wrapper.
Using your nondominant hand, pick up the dominant hand's glove by touching only the rolled cuff.
Pull the glove onto your dominant hand still only touching the inside of the glove.
Scoop up remaining glove by placing fingers of your dominant hand under the rolled cuff and pull onto nondominant hand.
Do not touch anything that is non-sterile!
Card 88
Sterile Field
Best Practices for Maintaining Sterility
Answer
Sterile Field - Best Practices
Never turn your back on a sterile field or leave a sterile field unattended.
Do not reach over sterile field.
Do not talk, cough, or sneeze over sterile field.
Check the packaging of all items for holes, damage, or moisture prior to use.
The 1" border of a sterile field is considered non-sterile.
Ensure working surface is at waist-level. Objects held below the waist are no longer sterile.
Sterile may touch sterile!
Card 89
Personal Protective Equipment (PPE)
Steps for Donning & Doffing PPE
Answer
Personal Protective Equipment (PPE)
Don (Put on)
Hand hygiene
Gown - tie to secure
Mask - cover nose and chin
Eye protection
Gloves - cover cuff of gown
GMEG: "GeeMeg, my patient is on isolation precautions!"
Doff (Take off)
Gloves
Eye protection
Gown
Mask
Hand hygiene
Avoid touching the outside of all PPE during removal, as it is contaminated.
Card 90
Hand Hygiene
Steps Using Soap & Water
Answer
Hand Hygiene - Soap & Water
Remove jewelry.
Wet hands and wrists thoroughly with warm water, keeping hands and forearms below elbows while washing.
Use 3 - 5 mL of antiseptic soap and rub hands together vigorously for at least 15 seconds.
Thoroughly cleanse palms, underneath fingernails, and between fingers.
Rinse hands and wrists. Water should flow toward fingertips.
Pat hands dry from fingers towards forearms.
Turn off faucet with clean, dry paper towel.
Card 91
Nursing Interventions
Best Practices:
- Pre-Intervention
- Post-Intervention
Answer
Nursing Interventions
Pre-Intervention:
- Verify orders.
- Gather all supplies before entering room.
- Follow standard precautions (e.g., hand hygiene).
- Identify patient using two identifiers.
- Provide privacy and ensure dignity.
- Complete necessary focused assessments prior to intervention.
- Raise bed to waist height.
Post-Intervention:
- Return patient to a comfortable position.
- Lower bed, raise side rails, ensure bed is locked.
- Ensure call bell is within patient's reach.
- Document interventions. If you don't chart it, it doesn't count!