FINAL CHECK-OFF

Clinical Procedures
Medication Administration
Intravenous Procedures
Urinary Catheterization
Wound Care
Gastrointestinal Tube
Traceostomy

MEDICATION ADMINISTRATION

IM or SQ injection
1. Wash Hands
2. Compare MAR with MD Orders: Client, Time, Drug, Dose, Route
3. Check Patient chart for allergies to medications or latex drugs
4. Take MAR to med cart
5. I am going to perform my three checks:
As I am taking med out of med cart
Before withdrawing med
After withdrawing med
6. Pull med from cart, checks with MAR
7. Which needle size to use for
IM injection: 19-23 gauge, 1½ in.
SQ injection: 25-27 gauge, 5/8 in.
8. Perform 2nd check before withdrawing med
9. Withdraw med:
Take off vial cap
Alcohol swab the top
Maintain sterile needle
Inject air into vial
With draw med w/ no bubbles
Recap using sweep method
Label needle
10. Perform the 3rd check after withdrawing medication
11. Go into patient room and introduce self and id patient; ask about
allergies
12. Wash hands/Gloves
13. Tell patient you are going to give him an IM injection, which puts
the medication
into the muscle. Explain what the med does and how it is useful.
14. Put the patient in the correct position to relax muscle and
minimize discomfort
15. Checks one last time.
16. Select site and Perform assessment:
Inflammation
Erythema
Make sure rotating site from last injection
Lesions
Tenderness
Swelling
Hardness
Bruising
17. Alcohol swab the site
18. Pull skin to the side for Z-track method
19. Hold syringe like a dart, push in quickly
20. Stabilize with non dominant hand, aspirate for 5 seconds and look
for air
If no air appears inject med slowly and pull needle out.
21. Properly dispose of needle- do not recap

22. Document:
On MAR: med and signature
Pre-administration assessment findings
Site utilized normal
Adverse effects
IM Injection sites
1. Ventrogluteal:
Place heel of hand on greater trochanter(right hand for left
hip)
Point fingers to the head
Make a triangle with index finger on anterior superior iliac
spine and
middle finger on iliac crest
Position: Side lying with knee bent towards chest
2. Vastus Lateralis:
Middle third of the thigh
Position: Back lying or sitting
3. Dorsogluteal:
Palpate posterior superior iliac spine
Draw imaginary line to greater trochanter
Site lateral and superior to the line
Position: Prone with toes inward
4. Deltoid:
3 fingers below acromion process
no more than 1 mL of solution
SQ Injection Sites
Abdomen
Lateral anterior arm
Upper thigh
 Scapular
Gluteal
Seven Essential Parts to a Medication Order
1. Client’s full name
2. Date and Time order written
3. Drug name
4. Dose of drug
5. Frequency
6. Route
7. Signature of person writing order
Ophthalmic Medication
1. Assessment:
Lesions
Exudates
Erythema
Swelling
Itching
Burning
Blurred vision
OD: right
OS: left
OU: both
2. Place client in a supine position with head slightly hyperextended
3. Clean eyelids eyelashes with sterile cotton ball moistened with NS-
wipe inner to outer
4. Place tissue below eyelid
5. Hold eyedropper ½ - ¾ in above eyeball
6. Ointment- discard first bead
7. Rest hand on client’s forehead
8. Tell client to look up
9. Drops into outer 1/3 of lower conjunctival sac
10. Instruct patient to close eyes and move eyes
11. Apply pressure to lacrimal ducts
Otic Medication
1. Assessment:
Signs of redness
Abrasions
Discharge
2. Side lying position with affected ear up
3. Clean: use cotton tipped applicators to wipe pinna and auditory
meatus
4. Straighten ear canal: Up and out/back
5. Hold dropper ½ in above ear
6. Press firmly on tragus a few times
7. Maintain position for 2-3 min
8. Cotton ball on outermost part of ear
Topical Skin Medication
1. Assessment:
2. Remove old patch
3. Clean site
4. Apply medication
Nasal Medication
1. Position patient so they are sitting upright
2. Ask pt to blow nose
3. Inhaler, ask to inhale while spray is administered
4. After- blot nose, but do not blow
Rectal
1. Position client in side lying position on left side with upper leg
drawn toward the chest
2. Towel or pad under patient
3. Assess external anus
4. Lubricate tip
5. Tell client they will experience a cool sensation and pressure
6. Encourage slow deep breaths
7. Separate buttocks and insert med
8. Wipe anal area
Vaginal
1. Ask client to void and help into a back lying position with knees
bent and hips rotated
laterally
2. Drape client and put towel or pad on bed
3. Assess clean perineal area; Assessment:
Inflammation
Amount, character, and odor of discharge
Complaint of vaginal discomfort-burning, itching
4. Retract labia
5. Insert applicator 2-3 in into the vagina

IV PROCEDURES

Primary Line
1. Wash Hands
2. Check MD order and MAR: date/time, med/fluid, route, dose/rate,
client name
3. Check drug book for compatibility and adverse rexns
4. Calculate drip rate
5. Choose correct fluid and tubing – make sure bag is clear with no
precipitates, cloudiness or leaks and check exp date
6. Attach calculation strip to bag: Date, int, start amount, middle,
quarter, end
Mark how many mL will pass with each hour
7. Label tubing- Date, time, int
 8. Close clamp on tubing, Remove plastic stopper from IV bag, and
insert tubing
9. Fill drip chamber ½ full
10. Prime tubing- Take off cap, open clamp, hold over trash
can
11. Prepare syringe with 3mL NS
12. Go to client’s room, Introduce yourself, and Id patient,
check allergies
13. Wash hands, gloves
14. Check 5 rights
15. Assess IV site for:
Phlebitis, pain, infiltration, inflammation, irritation, edema,
warmth, cool
16. Hang bag
17. Clean port with an alcohol swab
18. Flush port with 3 mL NS (if nothing running) or
incompatible
19. Connect new bag and tubing to port
20. Open clamp and regulate drip rate within 4 drops
21. Check arm again
22. Document date, time, type of solution, start and end time,
drip rate, condition of IV site, client response, signature

<100 mL/hr = Microdrip 60 gtts/mL

>100 mL/hr = Macro drip 10, 12, 15, 20 gtts/mL
Groshong style catheter- do not need to be heparinized because the
prevents blood from entering
Complications from IV Therapy:
1. Infiltration – Swelling, cool skin, blanching, discomfort, slowed
infusion rate
2. Hematona – discoloration, swelling, tenderness
3. Phlebitis – tenderness, redness, heat, edema
4. Tissue Sloughing – tissue necrosis
5. Infection – tenderness, swelling, erythema, induration, purulent
discharge

Peripheral IVAD: give IVPB

1. Check MD orders with MAR: date/time, drug, strength/dose,
route, client
2. Gather materials like med bag and tubing (need primary tubing),
tape, marker, alcohol, syringes
3. Label bag and tubing – time, date, flow rate
4. Prime tubing
5. Get syringes ready – 2, 3mL saline syringes
6. 2nd check for medications
 7. Calculate flow rate by looking in IV med book and Look up signs
for adverse rexns
8. Take into room – med bag w/ tubing, alcohol, 2 flushes, MAR
9. Introduce self, id patient, check allergies to medication
10. Wash hands/gloves
11. Assessment of site
12. Alcohol swab and flush
13. Attach tubing and set flow rate
14. Look at site again, any pain
15. Come back when med is infused, give second flush,
assess for adverse rexns
Compatible Primary IV infusing: start IVPB
Same steps, the difference is in the priming of tubing/ secondary
tubing
1. Prime tubing when hooked to primary line on the upper Y port
2. Open all the lines, let the med bag lower than the fluids
3. Set the fluid on a hanger lower than the med bag
4. Set drip rate with fluid bag drip chamber and let med bad wide
open
5. Check site again
Incompatible Primary IV: start IVPB
Need Primary tubing for med bag
1. 3 NS syringes with 3 mL each
2. Close off port by rolling down to lower Y clamp
3. Flush
4. Set up primary tubing at lower port
5. Set flow rate
6. Come back, flush, open clamp and roll back
Peripheral IVAD: IV Push
1. Wash hands
2. Check MAR with MD orders
3. 3 checks- a) when taking from med cart
b) before withdrawing med
c) after withdrawing med
4. Determine med action, SE, rate of administration
5. Calculate med dosage
6. Prepare 3mL NS syringe
7. Introduce self, id patient, determine allergies, explanation
8. Wash hands, clean gloves,
9. Assess insertion site
10. Take client VS
11. Take off port cap
12. Flush lock with 1mL of NS
13. Push med
14. Flush 1mL NS
15. Replace a new sterile cap over the lock
Compatible Primary Line: Give IV Push
1. You don’t need flush because you have a flush running
2. Use the port closest to the patient
3. Alcohol swab it
4. Clamp off the primary line
5. Administer med at recommended rate
6. Unclamp tubing
Incompatible Primary Line: Give IV Push
1. Need two syringes for flushes and I syringe with medication
2. Slide clamp down and close off
3. Wash hands/glove
4. Wipe port with alcohol swab
5. Flush with 2-3cc NS
6. Inject med
7. Second flush
8. Set clamp in previous position
Central Line
Triple Lumen
Brown port used for blood withdraws
With flush always use a 10cc syringe
Protocols tell you how much flush to use
Flushing a central catheter:
1. Wash hands, apply gloves
2. Prep 2 syringes – 10cc NS, 5cc Heparin
3. Swab injection cap/catheter hub with p-iodine and alcohol
4. Clamp catheter and remove cap
5. Check for patentcy
6. Attach syringe of NS
7. Release clamp
8. Aspirate heparin solution from catheter
9. Observe for blood return
10. Flush quickly with NS
11. Reclamp
12. Remove empty syringe Attach 5cc heparin syringe
13. Release clamp
14. Flush quickly
15. Reclamp
16. Place a new cap on catheter
17. Tape all tubing connections
18. Attach tubing to client’s clothing
19. Wash hands
20. Document: Condition of catheter, patentcy of
catheter(ability to draw blood), and report: occlusion, catheter
damage, air embolus
Starting a Central Line Infusion
1. If patient has no fluids running, flush with NS (10cc syringe)
 2.Look at protocols
3.Slide clamp should be clamped off
4.Wipe Port, and attach syringe
5.Unclamp sliding clamp, aspirate blood**, infuse NS
6.Before removing syringe, turn clamp off, then remove, and
attach tubing
7. Turn fluids on
Central Line Dressing
1. Wash hands/ clean gloves
2. Remove old dressing
3. Note drainage on dressing
4. Inspect skin at insertion site for redness, tenderness, swelling
5. Palpate catheter for Darcon cuff and document proper placement
6. Inspect Catheter
7. Remove gloves, wash hands, put on sterile gloves
8. Clean exit site with P-iodine – begin at catheter and move out in
a circular motion
9. Apply ointment to exit site
10. Apply sterile gauze dressing with tape
11. Label date and time of dressing change
12. Secure tubing to clothing
13. Document: date, time, type of ointment and dressing,
condition of skin, presence of exudates and bleeding

WOUND CARE & STERILE TECHNIQUE

Surgical Incision – wound created under sterile condition, center of

the incision is cleanest
1. Clean down the middle first, go down one side then down the
other with clean sponge each time
2. Drains should be cleaned last
3. Closed drain – prevents pocket of blood and bacteria, neg
pressure
(sanguinous – bloody drainage; serosanguinous – combination of
serous and blood)
4. Change every 2 hours, and record amount of drainage
Open wound – not surgically created; if it is not extremely dirty with
much exudate it is
not recommended to clean it bc you may destroy healing fiber
1. If it needs to be cleaned, irrigate or apply a wet-to-dry dressing
2. Center is considered most contaminated
Wet-to-dry
1. Physician does not want to surgically close incision so it is left
open
2. Physician does not want to close fluid inside
Sterile Field
1. Open away from you and set to side, 1in margin on all sides, You
can touch cloth underneath
2. Pouring Solution – Open NS can be kept 24 hrs, if it is already
opened, then dump some in the trash, put bowl to the side so
you do not have to reach over the sterile field, set cap down
facing up
3. Adding ointment – pour some ointment in the field or put on a
4X4
4. Put on sterile gloves last after you set everything up
5. You can use forceps to move things around
Sterile Gloving
1. Touch folded area
2. Make adjustments once gloves are on – watch where your fingers
are, hold over a sterile area,
3. Do not lower hands below waist
4. Take glove off – dirty-to-dirty, clean-to-clean
Dressing Change
1. Check MD orders for type of change, irrigation, or ointment
2. Introduce Self, Id Patient, Explain what you are going to do and
why
3. Wash hands/clean gloves/privacy
4. Assessment of old dressing:
Appearance and size of wound
Amount, character, and odor of exudates
Complaints of discomfort
Local Infection: Erythema, purulent drainage, swelling,
pain, inflammation
Signs of systemic infection: fever, diaphoresis, and malaise
5. Determine what supplies you need by assessing the wound –
number of gauzes saturated and diameter of drainage, dressing
change kit, Sterile NS, tape, Neosporin
6. Remove old dressing – pull tape gently but firmly toward wound
7. Ready to set up sterile field
8. Clean wound from clean to contaminated and clean drain last
(Penrose – half circle)
9. Apply new dressing
Dry heat – apply 4X4 to the wound, place abd pad on top
Moist heat – Wring NS out of 4X4 place on wound, dry
external dressing
Drain – cleanse area under drain, apply precut 4X4, top w/
4X4
10. Document: where the wound is, intact, kind of drainage,
odor, how many gauze saturated, condition of surrounding skin,
presence of drains, type of solutions used for cleaning, type old
dressing reapplies, client tolerance
Principles of Sterile Field
1. Tables about the waist
2. Open package in sterile field
3. Don’t put unsterile things in the field(ie. Tape)
4. Don’t turn your back on the sterile field
5. Hands above waist
6. Make sure you open everything before you put your sterile
gloves on
Irrigating a Wound
1. Check MD orders to determine type of irrigating solution,
frequency of irrigation, and temp of the solution
2. Check irrigating solution is at proper temp
3. Introduce self, ID Patient, Explain what you are going to do
4. Wash hands/glove/privacy
5. Position the client so solution will flow into the basin
6. Place waterproof drape over client and bed
7. Discard old dressing and assess wound drainage: Appearance
and size of the wound, character of exudates, signs of systemic
infection, pain
8. Open sterile dressing set and supplies
9. Position basin below the wound
10. Instill a steady stream of irrigating solution into the
wound, all areas
11. Continue irrigating until the solution becomes clear
12. Dry area around the wound
13. Use sterile technique to apply the dressing to the wound
14. Document: Irrigating, Pt response, character of exudates,
appearance and size of wound

URINARY CATHETERIZATION

1. Check MD orders and size of catheter

2. Gather catheter kit(ensure right size, exp date), drape for pt
3. Introduce self, ID patient, Ask about allergies to latex or iodine,
Explain what you are going to do why necessary; Tell patient she
it might feel like a voiding or urinating sensation
4. Wash hands/glove/privacy
5. Perform Abdominal Assessment:
Inspect: Contour – distended; full bladder
Symmetry – Shine light across, symmetrical
Umbilicus – midline, no discoloration, inflammation, or
hernia(lift head)
Skin – smooth and even, no visible peristalsis
Pulsation – Pulsations from aorta
Demeanor – comfortable, relaxed
Auscutate – bowel sounds present in all four quadrants
 Percuss – Tympany heard in all 4 quads with dullness noted
at two lower quads(urinary retention)

Palpate(light and deep) – no masses noted, ask for any

tenderness
6. Place client in appropriate position and drape exposed areas
Man – supine, legs abducted and laterally rotated
Woman – Supine, knees bents, legs laterally rotated
7. Stand on the client’s right if you are right-handed
8. Bring bed to waist level
9. Drape patient
10. Open kit- first away, side-to-side, and then front
11. Place waterproof drape under butt
12. Apply sterile gloves
13. Saturate cleaning balls with antiseptic solution
14. Open lubricant
15. Open specimen container and place it nearby with lid
loosely on top(if necessary)
16. Test balloon by filling it with sterile water; leave syringe
attached
17. Open lubricant and pour in pocket in box
18. Let pt know when you will expose them
19. Place fenestrated drape over penis
20. Clean meatus with nondominant hand
Woman: Use nondominant hand to spread labia
Pick up cleansing ball with forceps
Clean one side of labia majora, then other side; anterior-
posterior direction
Same for labia minora and use last ball to go over meatus
Man: Grasp penis just below glans with nondominant hand
Hold it firmly upright with slight tension
Wipe center of meatus in a circular motion out
21. Grasp catheter firmly 2-3 in from tip, ask client to take a
slow deep breath, and insert the catheter while pt exhaling
22. Advance catheter 2 in further after urine begins to flow
23. Next move nondominant hand to catheter and inflate the
balloon with the clean dominant hand
24. Pull gently on the catheter until resistance is felt
25. Change gloves
26. Collect urine specimen(if required): Allow 20-30mL to flow
into bottle with out touching the inside of the container
27. Secure catheter with enough slack to the thigh
28. Make sure bag is hung below the level of the bladder
29. Clean perineum and recover
 30. Documentation: date/time, name, amount and description
of urine, Catheter size and results, assessment findings, amount
of water instilled into balloon

Obtain a Sterile Specimen

1. Explain procedure
2. Wash hands/ gloves
3. Clamp foley until urine is seen
4. Wipe port with alcohol swab
5. Remove lid from ua bottle
6. insert needle, bevel up, and pull off 10cc
7. Put urine into cup w/out touching sides of cup
8. Discard sharps
9. Put lid back on bottle
10. Provide comfort
11. Clean up/remove gloves/wash hands
12. Documentation: Sterile specimen obtained, sent to lab,
side rails up, call light within reach
Draping
Woman:
1. Put drape in a triangle before you put legs up
2. The point of the triangle between her legs
3. Flex knees with feet flat on the bed and spread
4. Wrap tails around legs and when you are ready, open them
Male:
1. Lift gown until you see penis
2. Use bottom cover or bath blanket in between their legs

GASTROINTESTINAL TUBES

NG Tube Insertion
1. Check MD orders for type and size of tube
2. Gather supplies:
Tube
Solution basin filled with warm water
Tape
Lubricant
Tissue
Glass of water w/ straw
20-50mL syringe w/ adapter
pH strips
Stethoscope
Towel
Pen light
Tongue depressor
Safety pin
 3. Introduce self, id patient, explain what you are going to do: it is
not painful, but it may be uncomfortable bc gag reflex is
activated, ask if the client has any allergies or has dentures
4. Establish a method for the client to indicate distress
5. Wash hand/ privacy
6. Abdominal Assessment:
Inspect: Symmetrical, umbilicus midline without
discoloration, skin smooth and even, warm to touch
Pulsation: Aortal pulsation, no visible peristaltic waves
Auscultate: bowel soundsX4
Percuss: Tympanyx4
Palpate: No masses, tenderness
7. Nose Assessment:
Use pen light to check intactness of tissues-irritations,
abrasions
Examine for obstruction or deformity by asking to breath
through nostril while occluding the other
8. Determine how far to insert the tube – tip of nose to tip of ear
lobe to tip of xiphoid
9. Tear the tapes, one for measurement, other as trousers
10. Check patentcy of the tube
11. Gloves
12. Lubricate tip of tube well, insert tube with natural curve –
Ask client to hyperextend the neck
13. Direct tube along floor of nostril
14. As tube reached the throat ask client to lean head
forward and take sips of water,
Which closes epiglottis
15. Ascertain correct placement by aspirating stomach
contents and checking ph,
auscultating air, or X-ray
16. Clamp tube, Tape tube to client’s nose and secure to
gown
17. Document: Insertion of tube, means by which correct
placement was checked and
client response
Salem slump used for suctioning and Levine for feeding
Irrigation of NG Tube
1. Check MD orders
2. Gather Supplies:
NS
Irrigation Set
Towel
Stethoscope
3. Emesis Basin
4. Introduce self, ID patient, explain procedure
 5. Wash hands, privacy, gloves
6. Abdominal Assessment
7. Place towel under patient
8. Semi-fowlers Position
9. If on suction disconnect tube from suction
10. Check Placement
11. Inject 20-30 cc NS into tube
12. Pull back on syringe and empty into basin
13. Instill and withdraw until tube is patent
14. Reestablish suction
15. Document: Tube patent, any problems and pt rexn, how
many mLs irrigated with, and how much pulled back, color and
consistency of drainage, amount and type of irrigating solution,
time suction started and pressure established
Intermittent Tube Feeding
1. Check MD order
2. Gather supplies:
Feeding Solution
Irrigation set
Cup with water
Emesis basin
PH strip
3. Introduce self, id patient, explain procedure, ask about allergies
to any food
4. Wash hands, glove
5. Abdominal Assessment
6. Verify tube placement
7. Check residual
8. Attach syringe to NG tube and fill with a small amount of
contents and hold about 6 in about tube insertion
9. Fill syringe with feeding and allow to slowly flow
10. Flush with 30cc water
11. Clamp NG tube
12. Document: time of tube feeding, amount and what
feeding, tube placement verified, Assessment findings, Amount
of residual

Continuous Feeding
1. Check MD orders, Order is give for cc/hr, do not put more than 4
hours of feeding into the bag
2. Check placement and residual
3. Prime tubing and connect to NG tube
4. Turn on pump
Medication through NG tube
1. Liquid med or crushable tab that dissolves in water
2. Ensure 3 checks w/ 5 right
 3. Check placement
4. Give med and follow with water
Connecting NG tube to suction
1. Low-intermittent suction, watch for tube patentcy
2. Do abdominal assessment
3. Keep up with I&O
Initiating Suction:
1. Semi-fowlers
2. Check Placement
3. Intermittent Suction set at 80-100
4. Check suction level by occluding drainage tube
Salem sump tube(double lumen) – connect larger lumen to NG tube,
smaller tube provides a continuous flow of atmospheric air to prevent
excessive suction force, should always keep air vent tube higher than
the stomach to prevent reflux of stomach contents and keep drainage
collection chamber below the client’s stomach
Levine – single lumen NG tube, smaller so it is usually for feedings
5. Coil and pin tubing so that is does not go below the suction
bottle
6. Assess drainage – amount, color, odor, consistency
Maintaining suction:
1. After initiating suction assess client q30min until running
regularly, then q2hr
2. Assess for complains of fullness, nausea, epigastric pain, and
make sure there are flow of secretions
3. Inspect for patentcy or tightness of connections
4. Relieve blockages, reposition client, rotate NG tube
5. Irrigate NG tube
6. Apply mouth care q2-4hr
7. Empty drainage receptacle: clamp NG tube, turn off suction, note
amount, assess drainage, replace, turn on suction and unclamp
tube

TRACHEOSTOMY

Trach Care
1. Check MD orders
2. Gather equipment: Stethoscope, sterile drape, sterile NS and HP,
sterile 4x4 gauze, dressing
3. Introduce self, ID patient, explain what you are going to do, Tell
them to raise a hand or finger to signal distress
4. Wash hands
5. Semi-fowlers position
6. Chest assessment:
Inspect: Color, condition, lesions, rate, rhythm, and depth of airway
Palpate: Symmetric chest expansion
 Percuss: Hear resonance
Auscultate: clear or crackles
7. Place towel on chest
8. Clean gloves/throw away old trach dressing
9. Wash hands
10. Establish sterile field; open and organize supplies, check
exp dates
11. Pour NS and 2 HP into separate containers, 2 soaked
gauze with NS, 2 soaked gauze with HP
12. Sterile gloves
13. Unlock inner cannula with nondominant hand and pull it
towards you in line with curvature and place it in
14. HP solution for 2-3 min, clean with a brush and place in
NS, clean
15. Insert inner cannula and lock it into place
16. Clean insertion site/stoma and tube flange, wipe once
with NS gauze and discard
17. Clean faceplate first with HP gauze, next w/ NS gauge,
next with dry
18. Rinse and dry area thoroughly
19. Apply sterile dressing, use commertailly prepared or open
and refold 4x4 gauze to create V-shape
20. Apply dressing under flange but make sure it is supported
21. Change tracheostomy ties; enough to fit person’s neck
plus 6 in
22. Discard equipment, client comfort, bed rails up, lower
bed, call light
23. Wash hands
24. Document: Describe color, amount, and odor of
secretions, size and type of
tracheostomy in place, describe the condition of the stoma
including presence of secretions, color, edema, skin
breakdown
Trach Suctioning
Whistle tip – less irritating to tissues
Open tip – more effective at removing thick mucous plugs
Yankauer – Used to suction oral cavity
Symptoms that indicate need for suctioning: dyspnea, bubbling,
rattling breath sounds, cyanosis, decreased Sa02, inability to move
secretions
1. Check MD orders
2. Gather equipment: Ambu bag, suctioning equipment, sterile
drape and gloves, stethoscope(assessment),
3. Introduce self, id patient, explain what you are going to do
4. Wash hands/privacy
5. Semifowlers position/analgesic before suctioning
6. Assess patient, ant and post assessment:
Inspect: skin color, conditions, and respirations
Auscultate: anterior and posterior respirations
Palpate: symmetric expansion of the chest, tenderness, lumps,
masses
Percuss: anterior/posterior
7. Attach ambu bag to O2 source
8. Open sterile supplies
9. Place sterile drape across client’s chest
10. 100-120 pressure for suction
11. Pour sterile NS in sterile container
12. Put on sterile gloves
13. Hold catheter in dominant hand and connector in
nondominant hand attach
suction catheter to suction tubing
14. Flush and lubricate the catheter, place catheter tip in
sterile saline solution and with thumb of nondominant hand
occlude the thumb control and suction a small amount of NS
into the catheter
15. Hyperventilate lungs before suctioning, turn on 02 to 12-
15L/min, compress ambu bag 3-5 times (adequacy of ventilation
is assessed by rise and fall of the chest
16. Insert catheter (w/out suction) 5 in or until cough or
resistance
17. Apply intermittent suction for 5-10s, rotate catheter by
rolling it between the finger and thumb
18. Withdraw completely
19. Hyperventilate and suction again
20. Encourage client to breath deeply and cough between
suctioning
21. Allow 2-3 min between suctioning
22. Documentation: time/date, Findings of respiratory
assessment(pre and post
suctioning), description of secretions – color, amount, viscosity,
odor, number of time suction catheter inserted